What are the treatment options for tinnitus?

Treatment of Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be your primary therapeutic intervention. 1, 2

Initial Classification and Evaluation

Before initiating treatment, classify the tinnitus to identify potentially treatable underlying causes:

• Determine if tinnitus is pulsatile or non-pulsatile – pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) to identify treatable vascular abnormalities such as arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 1, 3
• Assess laterality – unilateral or asymmetric tinnitus requires comprehensive audiologic examination and may warrant MRI of the internal auditory canal with contrast to exclude vestibular schwannoma 1, 4
• Distinguish bothersome from non-bothersome tinnitus – this classification guides treatment intensity, as bothersome tinnitus significantly impacts quality of life and warrants active intervention 1, 2

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence)

1. Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life and should be recommended for all patients with persistent, bothersome tinnitus 1, 2
• CBT addresses the psychological distress and maladaptive thought patterns associated with tinnitus 1

2. Hearing Aids

• Recommend hearing aid evaluation for all patients with any degree of hearing loss and tinnitus, even if hearing loss is mild or unilateral 1, 2
• Hearing aids provide significant relief by amplifying environmental sounds and reducing the perception of tinnitus 1

3. Education and Counseling

• Provide education about tinnitus management strategies, natural history, and reassurance that tinnitus is not life-threatening for all patients with persistent tinnitus 1, 2
• This foundational intervention helps patients develop realistic expectations and coping strategies 1

Second-Line Treatment (Optional)

Sound Therapy

• May be recommended as a management option for symptomatic relief, though evidence is less conclusive than for CBT 1, 2
• Provides masking or habituation through environmental sounds or specialized devices 1

Treatments to AVOID (Strong Recommendations Against)

Do not routinely prescribe the following due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics – not recommended for primary treatment of persistent tinnitus unless treating comorbid psychiatric conditions 1, 2
• Intratympanic medications – lack evidence for routine use 1, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) – no consistent benefit demonstrated 1, 2
• Transcranial magnetic stimulation – not recommended for routine treatment 2

Special Clinical Scenarios

Pulsatile Tinnitus

• Obtain CTA or MRA of head and neck to evaluate for vascular abnormalities 3, 4
• Consider temporal bone CT as first-line imaging 3
• Treat underlying vascular cause when identified (e.g., anticoagulation for arterial dissection, surgical repair for sigmoid sinus dehiscence) 3

Tinnitus with Dizziness/Vertigo

• Consider Ménière's disease if vertigo episodes last 20 minutes to 24 hours with fluctuating hearing loss and aural fullness 4
• Obtain audiometry for all patients with this presentation 4
• Consider MRI of internal auditory canal with contrast to exclude vestibular schwannoma 4

Tinnitus with Psychiatric Comorbidity

• Promptly identify and intervene for patients with severe anxiety or depression due to increased suicide risk 1, 3
• This represents a medical emergency requiring immediate psychiatric evaluation 1

Critical Pitfalls to Avoid

• Do not overlook mild or unilateral hearing loss – these patients still benefit from hearing aid evaluation 1
• Do not obtain routine imaging for bilateral, non-pulsatile tinnitus without focal neurologic findings or asymmetric hearing loss – imaging is not indicated and wastes resources 1, 2
• Do not prescribe medications without clear evidence of benefit – this exposes patients to side effects without therapeutic gain 1
• Do not miss pulsatile tinnitus – this presentation requires vascular imaging to identify treatable and potentially dangerous causes 1, 3