What is the first line treatment of tinnitus?

First Line Treatment of Tinnitus

The first line treatment for persistent, bothersome tinnitus includes education and counseling about management strategies, hearing aid evaluation for those with hearing loss, and cognitive behavioral therapy (CBT). 1, 2

Initial Assessment and Classification

• Distinguish between bothersome and non-bothersome tinnitus, and determine if tinnitus is recent onset or persistent (≥6 months) to guide treatment decisions 2, 1
• Conduct a comprehensive audiologic examination, especially for unilateral, persistent tinnitus, or tinnitus associated with hearing difficulties 1, 3
• Classify tinnitus as pulsatile or non-pulsatile, as pulsatile tinnitus almost always requires imaging evaluation 3

First Line Treatment Options

Education and Counseling

• Provide education about tinnitus mechanisms, management strategies, and coping techniques to all patients with persistent, bothersome tinnitus 2, 1
• Education helps reduce anxiety, improves coping skills, and sets realistic expectations about treatment outcomes 1

Hearing Aid Evaluation

• Recommend hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus 2
• Hearing aids are beneficial even if hearing loss is only mild or unilateral 2, 1
• Hearing aids can improve quality of life by both addressing hearing loss and providing relief from tinnitus 2, 4

Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence base for improving quality of life in patients with persistent, bothersome tinnitus 1, 5
• CBT helps patients develop coping strategies and reduce tinnitus-related distress 1, 6
• The evidence is strongest for a combination of sound therapy and CBT-based counseling 4

Sound Therapy Options

• Sound therapy can be used as a complementary approach to first-line treatments 5, 7
• Sound therapy objectives include:
  • Producing relief from tinnitus-associated stress using soothing sounds 5
  • Passively diverting attention from tinnitus using background sound 5
  • Actively diverting attention using interesting sound 5
• Sound therapy can utilize environmental sounds, music, or speech 5, 7

Treatments to Avoid as First Line

• Do not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent, bothersome tinnitus 2, 1
• Avoid recommending dietary supplements such as Ginkgo biloba, melatonin, zinc, or other supplements for tinnitus treatment 2, 1
• There is insufficient evidence to recommend acupuncture for tinnitus treatment 1, 3

Special Considerations

• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to increased suicide risk 2, 3
• For patients with recent-onset tinnitus (less than 6 months), treatment may be deferred as spontaneous improvement is possible 2
• Pulsatile tinnitus requires different evaluation and management approaches than non-pulsatile tinnitus 3, 8

Treatment Algorithm

1. Determine if tinnitus is bothersome and persistent (≥6 months) 2, 1
2. Conduct audiologic evaluation to assess for hearing loss 1, 8
3. For patients with hearing loss, recommend hearing aid evaluation 2, 4
4. Provide education and counseling about tinnitus management strategies to all patients 2, 1
5. Recommend CBT for persistent, bothersome tinnitus 1, 6
6. Consider sound therapy as a complementary approach 5, 7
7. Avoid medications, supplements, and other interventions with insufficient evidence 2

This evidence-based approach focuses on treatments with demonstrated efficacy for improving quality of life in patients with tinnitus while avoiding interventions that lack sufficient supporting evidence.