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, 2

Initial Assessment and Classification

• Tinnitus should be classified as pulsatile or non-pulsatile, and primary or secondary, to guide appropriate treatment approaches 1
• A comprehensive otologic examination and audiologic evaluation are essential 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 one or more of the following are present: unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss 1
• Pulsatile tinnitus almost always requires imaging evaluation (CT angiography or MR angiography) to identify potentially treatable vascular causes 1, 3

Evidence-Based Treatment Options

First-Line Treatments

• Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in patients with persistent tinnitus 1, 4
• Hearing aids are recommended for patients with hearing loss and tinnitus, even if the hearing loss is only mild or unilateral 1
• Education and counseling about tinnitus management strategies are essential components for all patients with persistent tinnitus 1
• Sound therapy may provide symptomatic relief for persistent tinnitus 1

Treatments Not Recommended

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications 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

• Patients with severe anxiety or depression related to tinnitus require prompt identification and intervention due to increased suicide risk 1
• For tinnitus relieved by neck pressure, evaluation for vascular etiologies is recommended, as this may indicate treatable conditions such as arterial dissection, sigmoid sinus diverticulum, or jugular bulb abnormalities 3
• Tinnitus associated with medication use (such as Ativan/lorazepam) should be evaluated for temporal relationship to medication initiation or dose changes 2

Treatment Algorithm

1. Identify tinnitus characteristics:

   • If pulsatile or unilateral → Obtain appropriate imaging (CT, CTA, or MRA) 1, 3
   • If non-pulsatile and bilateral → Proceed with audiologic evaluation 1

2. Address any underlying treatable conditions:

   • Vascular abnormalities → Targeted treatment (surgical repair, endovascular embolization) 3
   • Hearing loss → Hearing aid evaluation 1
   • Medication-induced → Consider medication adjustment 2

3. For persistent, bothersome tinnitus:

   • Implement CBT as primary intervention 1, 5
   • Provide education and counseling 1
   • Consider sound therapy for symptomatic relief 1
   • Fit hearing aids if hearing loss is present 1, 6

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, 6
• Failing to identify patients with severe anxiety or depression who require additional psychiatric support 1
• Not obtaining imaging for patients with pulsatile tinnitus, which may indicate serious underlying vascular pathology 1, 3