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 cope and improves treatment outcomes 1

Second-Line Treatment (Optional)

Sound Therapy

• May be recommended as a management option for symptomatic relief in persistent tinnitus 1, 2
• Evidence is less conclusive than for CBT, but it provides masking and habituation benefits 1

Treatments to AVOID (Strong Recommendations Against)

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

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications – lack evidence for primary tinnitus treatment and may cause side effects 1, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) – no consistent benefit demonstrated 1, 2
• Transcranial magnetic stimulation – insufficient evidence for routine use 2

Important Exception

• Antidepressants or anxiolytics may be appropriate when treating comorbid depression or anxiety disorders, but not for tinnitus itself 1

Special Clinical Scenarios

Pulsatile Tinnitus

• Obtain CTA or MRA of the head and neck to identify vascular abnormalities 3, 4
• Dedicated temporal bone CT is recommended as first-line imaging 3
• Treatable causes include arterial dissection (anticoagulation/antiplatelet therapy), sigmoid sinus diverticulum (surgical repair or endovascular embolization), and jugular bulb abnormalities (surgical intervention) 3

Tinnitus with Dizziness/Vertigo

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

Psychiatric Comorbidity

• Promptly identify and intervene for patients with severe anxiety or depression due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 3
• This represents a medical emergency requiring immediate psychiatric referral 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 imaging for bilateral, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss – imaging is not indicated and wastes resources 1, 2
• Do not prescribe medications or supplements without clear evidence – this exposes patients to side effects without benefit 1, 2
• Do not miss pulsatile tinnitus – this almost always requires vascular imaging to identify treatable causes 1, 3

Practical Treatment Sequence

1. Classify tinnitus (pulsatile vs. non-pulsatile, unilateral vs. bilateral, bothersome vs. non-bothersome) 1
2. Obtain comprehensive audiologic examination for unilateral, persistent (≥6 months), or hearing-associated tinnitus 1, 2
3. Order imaging only if indicated (pulsatile, unilateral, focal neurologic signs, or asymmetric hearing loss) 1, 2
4. Provide education and counseling to all patients 1, 2
5. Refer for hearing aid evaluation if any hearing loss is present 1, 2
6. Recommend CBT for persistent, bothersome tinnitus 1, 2
7. Consider sound therapy as adjunctive treatment 1, 2
8. Screen for and treat psychiatric comorbidities separately from tinnitus 1