How to treat tinnitus?

Treatment Approaches for Tinnitus

Cognitive Behavioral Therapy (CBT) is the strongest evidence-based treatment for improving quality of life in patients with persistent, bothersome tinnitus. 1

Initial Assessment and Classification

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary, to guide appropriate treatment 1
• Pulsatile tinnitus almost always requires imaging evaluation to identify potentially treatable vascular causes 1, 2
• Non-pulsatile bilateral tinnitus typically does not require imaging unless accompanied by neurological deficits or head trauma 3

First-Line Treatment Options

• Hearing aids are recommended for patients with tinnitus and hearing loss, even if the hearing loss is only mild or unilateral 1
• Education and counseling are essential components for all patients with persistent tinnitus 1
• Sound therapy may provide symptomatic relief for persistent tinnitus 1

Evidence-Based Treatments

• CBT has the strongest evidence for improving quality of life in tinnitus patients 1, 4, 5
• For patients with identified vascular causes of tinnitus (especially pulsatile), targeted treatment of the underlying condition is recommended 6
• Physical therapy, postural adjustments, or manual therapy may benefit patients with somatic tinnitus related to cervical nerve or muscle dysfunction 6

Treatments Not Recommended

• Antidepressants, anticonvulsants, and anxiolytics are not recommended for primary treatment of persistent tinnitus due to insufficient evidence and potential side effects 1
• Dietary supplements, including Ginkgo biloba, melatonin, zinc, or other supplements, should not be recommended due to lack of consistent benefit 1, 5

Special Considerations

• Prompt identification and intervention are necessary for patients with severe anxiety or depression due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 2
• Approximately 20% of adults with tinnitus require clinical intervention 2, 4
• Tinnitus is not a disease but a symptom that can result from numerous underlying causes 2

Common Pitfalls to Avoid

• Prescribing medications without clear evidence of benefit that may cause side effects or worsen tinnitus 1
• Recommending dietary supplements that lack evidence of efficacy 1
• Overlooking mild hearing loss that could benefit from hearing aid intervention 1
• Failing to evaluate pulsatile tinnitus with appropriate imaging studies 3, 1

Treatment Algorithm

1. Determine if tinnitus is pulsatile or non-pulsatile 1

   • If pulsatile: Obtain imaging (CT or MRI) to evaluate for vascular abnormalities 3, 6
   • If non-pulsatile: Proceed with audiologic evaluation 3, 5

2. Identify and address any underlying treatable conditions 1

   • For vascular causes: Consider targeted interventions such as surgery or embolization 6
   • For hearing loss: Recommend hearing aids 1

3. For persistent bothersome tinnitus without identifiable/treatable cause:

   • Implement CBT as primary intervention 1, 4, 5
   • Provide education and counseling 1
   • Consider sound therapy as supplementary treatment 1, 5