What is the best way to manage tinnitus caused by benzodiazepine (BZD) withdrawal?

Managing Tinnitus from Benzodiazepine Withdrawal

Tinnitus during benzodiazepine withdrawal is a recognized protracted withdrawal symptom that may persist for weeks to over 12 months, and the primary management strategy is to slow or pause your taper until symptoms stabilize, rather than attempting to treat the tinnitus directly. 1

Why Tinnitus Occurs During Benzodiazepine Withdrawal

Tinnitus is specifically listed as part of protracted benzodiazepine withdrawal syndrome, which occurs due to neuroadaptive changes in the central nervous system after chronic benzodiazepine use 1. The FDA drug label for clonazepam explicitly identifies tinnitus as a withdrawal symptom that "persists beyond 4 to 6 weeks after initial benzodiazepine withdrawal" and may last "weeks to more than 12 months" 1.

• Benzodiazepines cause physiological adaptation in the brain's GABA receptors, and withdrawal represents the reversal of these changes 1
• The auditory system's hyperexcitability during withdrawal manifests as tinnitus, similar to other perceptual hypersensitivity symptoms 1, 2
• Case reports document tinnitus emerging even during gradual tapers (one patient developed it after reducing clonazepam to 50% of the original dose over 7 weeks) 2

Management Strategy for Withdrawal-Related Tinnitus

Modify Your Taper Schedule

The taper rate must be determined by your tolerance to withdrawal symptoms, not by a rigid schedule, and pauses in the taper are acceptable and often necessary when withdrawal symptoms like tinnitus emerge 3. This is the most critical intervention.

• Immediately slow or pause your benzodiazepine taper when tinnitus develops 3, 2
• Consider reducing by only 10% of your current dose per month (not the original dose) if you've been on benzodiazepines for more than 1 year 3
• The reduction should be a percentage of the current dose, not the original dose, to prevent disproportionately large final reductions 3
• Some patients may need to extend their taper over many months to years to avoid debilitating withdrawal symptoms 3, 2

Adjunctive Pharmacological Support

While no medication specifically treats benzodiazepine withdrawal tinnitus, certain adjuncts may help manage overall withdrawal symptoms:

• Gabapentin can mitigate withdrawal symptoms during benzodiazepine tapering, starting at 100-300 mg at bedtime or three times daily, increasing by 100-300 mg every 1-7 days as tolerated 3
• Carbamazepine may have adjunctive properties for assisting benzodiazepine discontinuation, though data are limited 4, 5
• Pregabalin has shown potential benefit in facilitating benzodiazepine tapering 3
• SSRIs (particularly paroxetine) may help manage underlying anxiety during tapering, though they do not directly treat tinnitus 3

Non-Pharmacological Approaches

• Cognitive-behavioral therapy (CBT) during the taper increases success rates and should be incorporated, particularly for patients struggling with discontinuation 3
• Psychological support including mindfulness and relaxation techniques should be part of your withdrawal management 3
• Supportive therapy and patient education about the temporary nature of withdrawal symptoms can improve outcomes 4, 3

Monitoring Requirements

• Follow up at least monthly during the taper, with more frequent contact needed during difficult phases when symptoms like tinnitus emerge 3
• Monitor for other withdrawal symptoms including anxiety, insomnia, perceptual hypersensitivity, and mood changes 3, 1
• Be aware that distinguishing between withdrawal symptoms and re-emergence of the original condition for which benzodiazepines were prescribed can be challenging 1

Critical Safety Warnings

• Abrupt discontinuation of benzodiazepines can cause seizures and death - never stop suddenly 3, 1
• Benzodiazepine withdrawal carries greater risks than opioid withdrawal and must always be conducted gradually 3
• If you're taking both opioids and benzodiazepines, the benzodiazepine should be tapered first due to higher withdrawal risks 3

When to Seek Specialist Help

Refer to a specialist if:

• You have a history of withdrawal seizures 3
• You have unstable psychiatric comorbidities 3
• Office-based tapering has been unsuccessful 3
• You have co-occurring substance use disorders 3

Important Caveats

• Tinnitus from benzodiazepine withdrawal is rare but can be debilitating and long-lasting 2
• The persistence of tinnitus may prevent further dose reductions, requiring an extended or indefinite pause in tapering 2
• There is difficulty differentiating whether tinnitus represents withdrawal or re-emergence of an underlying condition 1
• No specific treatment exists for withdrawal-induced tinnitus beyond slowing the taper and providing supportive care 2