What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the strongest evidence-based treatment for improving quality of life in patients with persistent, bothersome tinnitus and should be recommended as first-line therapy. 1

Initial Classification and Evaluation

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary, to guide appropriate treatment approaches 1
• A comprehensive otologic examination is essential to identify potentially treatable underlying conditions that may cause tinnitus 2, 1
• Audiologic evaluation is necessary for patients with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties 1
• Imaging studies should not be obtained for tinnitus evaluation unless the tinnitus is unilateral, pulsatile, associated with focal neurological abnormalities, or accompanied by asymmetric hearing loss 1

Evidence-Based Treatment Options

First-Line Treatments

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life and should be offered to patients with persistent, bothersome tinnitus 1
• Hearing aids are recommended for patients with hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1
• Education and counseling about tinnitus management strategies are essential components for all patients with persistent tinnitus 2, 1
• Sound therapy may provide symptomatic relief for persistent tinnitus 1

Treatments Not Recommended

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

Special Considerations

Pulsatile Tinnitus

• Pulsatile tinnitus almost always requires imaging evaluation (CTA or MRA) to identify potentially treatable vascular causes 1, 3
• Common causes include arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 3
• Treatment depends on the specific vascular abnormality identified 3

Psychological Aspects

• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention, as suicide has been reported in patients with tinnitus who have coexisting psychiatric illness 2, 1
• Addressing psychological comorbidities is crucial for improving quality of life in tinnitus patients 1

Treatment Algorithm

1. Determine if tinnitus is bothersome - Only bothersome tinnitus requires active management 1
2. Identify and treat any underlying causes - Perform targeted history and physical examination 2, 1
3. For persistent primary tinnitus:
   • Provide education and counseling about tinnitus management strategies 1
   • Recommend CBT as first-line therapy 1
   • For patients with hearing loss, recommend hearing aid evaluation 1
   • Consider sound therapy as a management option 1
4. For pulsatile tinnitus:
   • Obtain appropriate imaging (CTA or MRA) 1, 3
   • Treat the underlying vascular abnormality if identified 3

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 identify and address psychological comorbidities 2, 1
• Neglecting to obtain imaging for unilateral or pulsatile tinnitus 1