Can Ativan (lorazepam) cause tinnitus (ringing in the ears)?

Ativan (Lorazepam) and Tinnitus

Ativan (lorazepam) can cause tinnitus (ringing in the ears), particularly during withdrawal from the medication. According to the FDA drug label, tinnitus is specifically listed as a symptom of protracted withdrawal syndrome associated with benzodiazepines 1.

Mechanism and Evidence

• Tinnitus is the perception of sound when no external sound is present, affecting approximately 10% of the US adult population 2.
• Benzodiazepines like Ativan can cause tinnitus through multiple mechanisms:
  • Direct ototoxicity during regular use 3
  • As part of protracted withdrawal syndrome that can persist beyond 4-6 weeks after initial benzodiazepine discontinuation 1
  • Through interaction with serotonergic, glutamatergic, and GABAergic neurotransmitter systems that process cochlear input 4

Clinical Presentation

• Tinnitus may be described as various sounds including hissing, buzzing, ringing, pulsations, or clicking noises 5.
• Tinnitus related to Ativan may present as:
  • New onset during regular use of the medication
  • Emerging or worsening during dose reduction
  • Appearing after discontinuation of the medication 1
• The tinnitus may be bilateral (affecting both ears) and non-pulsatile in nature 2

Risk Factors

• Higher dosages and longer duration of benzodiazepine use increase risk of withdrawal symptoms including tinnitus 1
• Abrupt discontinuation rather than gradual tapering significantly increases risk 1
• Pre-existing cochlear impairment may predispose patients to medication-induced tinnitus 6
• Concurrent or recent use of other potentially ototoxic medications (e.g., aspirin, certain antibiotics) may increase risk 4, 6

Management

• If tinnitus develops during Ativan use:

  • Consider if the tinnitus began specifically after starting the medication or after dose reduction 5
  • For withdrawal-related tinnitus, stabilizing the dose may help reduce symptoms 5
  • If discontinuation is necessary, use a gradual tapering schedule rather than abrupt discontinuation 1

• For persistent tinnitus:

  • Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent tinnitus 7
  • Sound therapy may provide symptomatic relief 7
  • Hearing aids may be beneficial if there is associated hearing loss 7

Important Considerations

• Protracted withdrawal symptoms from benzodiazepines may last weeks to more than 12 months 1
• There may be difficulty differentiating withdrawal symptoms from potential re-emergence of symptoms for which the benzodiazepine was being used 1
• Alprazolam (another benzodiazepine) has shown mixed results in tinnitus treatment, with some studies showing improvement in visual analog scale scores but not in Tinnitus Handicap Inventory scores 8, 9

When to Seek Further Evaluation

• If tinnitus is unilateral, pulsatile, or associated with hearing loss, a comprehensive audiological examination is recommended 5
• For non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss, imaging studies are generally not recommended 5
• If tinnitus persists despite addressing potential withdrawal, consider other etiologies and appropriate evaluations 5