Clonazepam for Tinnitus: Mechanism and Efficacy

Clonazepam is not recommended as a primary treatment for tinnitus due to insufficient evidence of benefit and potential side effects. 1, 2

Mechanism of Action in Tinnitus

Clonazepam, a long-acting benzodiazepine, promotes GABAergic inhibition by increasing the frequency of chloride channel opening, which may reduce central nervous system hyperexcitability potentially associated with tinnitus 3
Benzodiazepines like clonazepam may reduce the subjective sensation of tinnitus by addressing anxiety and sleep disturbances that often accompany and exacerbate tinnitus perception 3
Clonazepam may help manage the psychological distress associated with tinnitus rather than treating the underlying cause of the phantom sound 4

A retrospective survey of clinical experience found that clonazepam improved tinnitus in only 32% of patients, which is significantly lower than its efficacy for vertigo (77.4%) 5
Short-acting benzodiazepines like alprazolam have shown some efficacy for anxiety signs related to tinnitus, but not for the primary tinnitus perception itself 4
Current clinical practice guidelines from the American Academy of Otolaryngology-Head and Neck Surgery explicitly do not recommend anxiolytics (including benzodiazepines) for primary treatment of persistent tinnitus due to insufficient evidence and potential side effects 1, 2

Common adverse effects of clonazepam include daytime sleepiness, dizziness, and postural instability, which can be particularly problematic in elderly patients 3
Long-term use carries risks of tolerance, dependence, and cognitive impairment 3
Clonazepam is listed on the American Geriatrics Society Beers Criteria as a potentially inappropriate medication in older adults 3

Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus 1, 2
Hearing aid evaluation is recommended for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1, 2
Education and counseling about tinnitus management strategies should be provided to all patients with persistent tinnitus 2

Clonazepam may be considered when tinnitus is accompanied by severe anxiety or depression that significantly impacts quality of life, but should not be the primary treatment for tinnitus itself 3
For patients with both REM sleep behavior disorder and tinnitus, clonazepam might address both conditions, as it is recommended for REM sleep behavior disorder 3
Short-term use may be appropriate during acute exacerbations of tinnitus-related distress, but long-term management should focus on evidence-based approaches like CBT 4

Prescribing benzodiazepines for tinnitus without addressing underlying hearing loss or psychological factors 1, 2
Using clonazepam as a first-line treatment rather than evidence-based approaches like CBT and hearing aids 1, 2
Failing to recognize that improvement in tinnitus perception with clonazepam may be due to its anxiolytic effects rather than direct action on tinnitus mechanisms 4, 6
Overlooking the risk of dependence and cognitive impairment with long-term benzodiazepine use, especially in older adults 3