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 one or more of these features are present:

• Unilateral or asymmetric tinnitus 1
• Pulsatile tinnitus 1, 2
• Focal neurological abnormalities 1
• Asymmetric hearing loss 1

Common Pitfalls to Avoid

Do not prescribe medications without clear evidence of benefit - this exposes patients to side effects without addressing the underlying problem 1

Do not overlook mild hearing loss - even minimal hearing impairment can benefit from hearing aid intervention 1

Do not miss pulsatile tinnitus - this almost always requires vascular imaging to identify treatable causes 1, 2

Do not recommend dietary supplements - these lack evidence of efficacy and waste patient resources 1, 2

Special Clinical Scenarios

For tinnitus relieved by neck pressure:

• This suggests vascular etiology requiring imaging evaluation 2
• Consider somatic tinnitus related to cervical dysfunction, which may benefit from physical therapy or manual therapy 2

For tinnitus with dizziness:

• Consider Ménière's disease when accompanied by episodic vertigo (20 minutes to 24 hours), fluctuating hearing loss, and aural fullness 4
• Treatment focuses on symptom management as there is no cure 4