What are the management options for tinnitus?

Management Options for Tinnitus

The most effective management strategy for persistent, bothersome tinnitus is cognitive behavioral therapy (CBT), which has the strongest evidence for improving quality of life in tinnitus patients. 1, 2

Initial Evaluation and Classification

• Perform a targeted history and physical examination to identify potentially treatable underlying conditions that may cause tinnitus 3
• Distinguish between bothersome and non-bothersome tinnitus, as this classification guides treatment decisions 3
• Differentiate between recent onset and persistent tinnitus (≥6 months) to prioritize intervention and guide management 3, 4
• Obtain a comprehensive audiologic examination for patients with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties 3, 5
• Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status 3
• Do not obtain imaging studies for tinnitus evaluation unless one or more of the following are present: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 3

Evidence-Based Management Options

First-Line Approaches

• Provide education and counseling about tinnitus management strategies for patients with persistent, bothersome tinnitus 3, 2
• Recommend a hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus, even if hearing loss is mild or unilateral 3, 2, 6
• Recommend cognitive behavioral therapy (CBT) for patients with persistent, bothersome tinnitus 3, 7
• Consider sound therapy (background noise, nature sounds, white noise machines) to mask tinnitus and reduce its perception 3, 1, 8

Treatments to Avoid

• Do not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for treating persistent, bothersome tinnitus 3, 2
• Do not recommend dietary supplements such as Ginkgo biloba, melatonin, zinc, or other supplements for tinnitus management due to lack of evidence 3, 1
• Do not recommend transcranial magnetic stimulation (TMS) for routine treatment of persistent, bothersome tinnitus 3

Special Considerations

• For pulsatile tinnitus, consider vascular causes and obtain appropriate imaging (CTA or MRA) to identify potentially treatable conditions 3, 2
• For patients with tinnitus and severe anxiety or depression, provide prompt identification and intervention due to increased suicide risk 3, 9
• For patients with sound tolerance problems (hyperacusis), consider measuring loudness discomfort levels at audiometric frequencies 4

Management Algorithm

1. For all patients with tinnitus:

   • Perform targeted history and physical exam 3
   • Determine if tinnitus is bothersome or non-bothersome 3
   • Determine if tinnitus is recent onset or persistent 3

2. For patients with unilateral, persistent, or hearing difficulty-associated tinnitus:

   • Obtain comprehensive audiologic examination 3
   • Consider imaging if tinnitus is unilateral, pulsatile, or associated with asymmetric hearing loss or neurological abnormalities 3

3. For patients with persistent, bothersome tinnitus:

   • Provide education and counseling 3
   • If hearing loss is present, recommend hearing aid evaluation 3, 6
   • Recommend cognitive behavioral therapy 3, 7
   • Consider sound therapy 3, 8
   • Avoid medications without clear evidence of benefit 3
   • Avoid dietary supplements 3

4. For patients with pulsatile tinnitus:

   • Obtain appropriate imaging (CTA or MRA) 3
   • Refer to appropriate specialist based on findings 3