What is the first-line treatment for tinnitus?

First-Line Treatment for Tinnitus

Education and counseling should be provided to all patients with persistent, bothersome tinnitus as the universal first-line intervention, followed by hearing aid evaluation if hearing loss is present, and cognitive behavioral therapy (CBT) for those with significant quality of life impairment. 1, 2

Initial Management Algorithm

Step 1: Determine Duration and Severity

• Distinguish persistent tinnitus (≥6 months) from recent onset to identify patients most likely to benefit from intervention 1, 3
• Classify as bothersome versus non-bothersome, as this guides treatment intensity 2, 3

Step 2: Universal First-Line Intervention

• Provide education and counseling about management strategies to ALL patients with persistent, bothersome tinnitus 1, 2, 3
• This has a preponderance of benefit over harm and forms the foundation of management 1

Step 3: Assess for Hearing Loss

• Obtain comprehensive audiologic examination for unilateral, persistent, or hearing-associated tinnitus 3
• If ANY degree of hearing loss is present (even mild or unilateral), recommend hearing aid evaluation immediately 1, 2, 3
• Hearing aids are explicitly described as a "first-line audiologic intervention" with high confidence in the evidence 1
• The benefit exists even for marginal hearing aid candidates 1

Step 4: Add CBT for Persistent Bothersome Cases

• Recommend CBT for patients with persistent, bothersome tinnitus 1, 2, 3
• CBT has the strongest evidence from RCTs for improving quality of life 2, 4, 5, 6
• This is particularly important when tinnitus causes significant functional impairment 4, 5

Optional Adjunctive Therapy

• Sound therapy may be recommended as an additional management option for symptomatic relief 1, 7, 8
• This can involve environmental sound, music, or speech to passively or actively divert attention from tinnitus 7

Critical Pitfalls to Avoid

Do NOT Use These as First-Line:

• Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics (including benzodiazepines like clonazepam), or intratympanic medications 1, 2, 3, 9
• These have insufficient evidence, methodological concerns in trials, and significant potential side effects 1
• Do NOT recommend dietary supplements (Ginkgo biloba, melatonin, zinc) due to lack of consistent benefit 2, 3
• Do NOT recommend transcranial magnetic stimulation for routine treatment 2

Imaging Considerations:

• Do NOT obtain imaging unless: unilateral tinnitus, pulsatile tinnitus, focal neurologic abnormalities, or asymmetric hearing loss are present 1, 3, 6
• For pulsatile tinnitus specifically, temporal bone CT or CTA of head/neck is appropriate first-line imaging to identify treatable vascular causes 1

Special Psychiatric Considerations

• Promptly identify and intervene for patients with severe anxiety or depression, as suicide risk is increased in tinnitus patients with psychiatric comorbidity 1, 3
• In these cases, addressing the psychiatric condition is critical, though anxiolytics should still not be used primarily for tinnitus itself 9

Evidence Strength

The guideline recommendations are based on Grade B evidence from RCTs for CBT 1, Grade C observational evidence for hearing aids (but with high confidence) 1, and consistent expert consensus across multiple guidelines 1, 2, 3. The strongest single intervention for quality of life improvement is CBT 2, 4, 5, while hearing aids address the underlying hearing loss that frequently accompanies tinnitus 2, 5.