What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with the strongest evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be the cornerstone of management. 1

Evidence-Based Treatment Algorithm

First-Line Interventions

For all patients with persistent, bothersome tinnitus:

• Provide education and counseling about tinnitus management strategies as an essential component of care 1
• Recommend CBT, which has the strongest evidence base for improving quality of life 1

For patients with any degree of hearing loss (even mild or unilateral):

• Recommend hearing aid evaluation and fitting, as hearing aids provide significant relief 1
• This applies even when hearing loss is minimal or affects only one ear 1

For patients with pulsatile tinnitus:

• Imaging evaluation is almost always required (CTA or MRA) to identify potentially treatable vascular causes 1, 2
• Treatable vascular abnormalities include arterial dissection, sigmoid sinus diverticulum/dehiscence, jugular bulb abnormalities, and aberrant vascular anatomy 2

Additional Management Options

Sound therapy may be offered for symptomatic relief in persistent tinnitus 1

For tinnitus with psychiatric comorbidity:

• Promptly identify and intervene for severe anxiety or depression due to increased suicide risk 1, 2
• Address mood disorders and sleep disturbances as secondary targets, not primary tinnitus treatment 3

Treatments NOT Recommended

The following should NOT be routinely prescribed for primary tinnitus treatment:

• Antidepressants, anticonvulsants, or anxiolytics - insufficient evidence and potential side effects 1, 2
• Intratympanic medications - lack of evidence for persistent tinnitus 1
• Dietary supplements (Ginkgo biloba, melatonin, zinc) - no consistent benefit demonstrated 1, 2

Critical Diagnostic Considerations Before Treatment

Obtain comprehensive audiologic examination when tinnitus is:

• Unilateral 1
• Persistent (≥6 months) 1
• Associated with hearing difficulties 1

Obtain imaging studies ONLY when:

• Tinnitus is unilateral or pulsatile 1
• Focal neurological abnormalities present 1
• Asymmetric hearing loss identified 1

Common Pitfalls to Avoid

• Do not prescribe medications without clear evidence of benefit - they may cause side effects or worsen tinnitus 1
• Do not overlook mild hearing loss - even minimal hearing loss can benefit from hearing aid intervention 1
• Do not miss pulsatile tinnitus - this almost always requires vascular imaging to identify treatable causes 2, 4
• Do not dismiss psychiatric symptoms - severe anxiety or depression requires urgent intervention due to suicide risk 1, 4