What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the most strongly recommended treatment for persistent, bothersome tinnitus based on the strongest evidence for improving quality of life. 1, 2

First-Line Treatment Approaches

• CBT should be recommended as the primary treatment for patients with persistent, bothersome tinnitus, as it has the strongest evidence base for improving quality of life 1, 2, 3
• Hearing aid evaluation should be offered to patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1, 2, 4
• Education and counseling about tinnitus management strategies should be provided to all patients with persistent, bothersome tinnitus 1, 2
• Sound therapy may provide symptomatic relief for persistent tinnitus 2, 5

Treatment Approaches Not Recommended

• Medical therapy including antidepressants, anticonvulsants, anxiolytics (including benzodiazepines like clonazepam), or intratympanic medications should not be used for treating persistent, bothersome tinnitus due to insufficient evidence and potential side effects 1, 2, 6
• Dietary supplements such as Ginkgo biloba, melatonin, zinc, or other supplements should not be recommended for tinnitus treatment due to lack of consistent benefit 1, 2
• Transcranial Magnetic Stimulation (TMS) should not be recommended for routine tinnitus treatment 1

Treatment Algorithm

1. Initial Assessment:

   • Distinguish between bothersome and non-bothersome tinnitus 1, 2
   • Determine if tinnitus is recent onset or persistent (≥6 months) 1, 2
   • Conduct comprehensive audiologic examination, especially for unilateral, persistent tinnitus, or tinnitus associated with hearing difficulties 1, 2

2. Treatment Selection:

   • For patients with hearing loss: Recommend hearing aid evaluation, even for mild or unilateral hearing loss 1, 2, 7
   • For all patients with persistent, bothersome tinnitus: Recommend CBT 1, 2, 8
   • For all patients: Provide education and counseling about tinnitus management strategies 1, 2

3. Special Considerations:

   • For pulsatile tinnitus: Consider vascular causes and obtain appropriate imaging 2
   • For patients with severe anxiety or depression: Address these conditions promptly due to increased suicide risk 2

Evidence Strength and Clinical Pearls

• The combination of sound therapy and CBT-based counseling has the strongest evidence base, though clinical trials are limited by patient heterogeneity 4
• Hearing aids have shown significant benefit in patients with tinnitus and hearing loss, with studies showing greater improvement in tinnitus handicap scores compared to counseling alone 7
• Despite ongoing research, there are no proven effective pharmacological treatments specifically for chronic tinnitus 4, 8

Common Pitfalls to Avoid

• Prescribing medications without clear evidence of benefit that may cause side effects or worsen tinnitus 2, 6
• Recommending dietary supplements that lack evidence of efficacy 1, 2
• Overlooking mild hearing loss that could benefit from hearing aid intervention 1, 2, 7
• Telling patients they must "learn to live with" their tinnitus without offering evidence-based interventions like CBT or hearing aids 5