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:

• Education and counseling are essential first steps to help patients understand tinnitus is not life-threatening and to discuss management strategies 1
• CBT should be recommended as it has the strongest evidence base for improving quality of life 1, 2

For patients with any degree of hearing loss:

• Hearing aids should be recommended even if hearing loss is mild or unilateral, as they provide significant relief and are a first-line treatment 1
• Hearing aid evaluation is indicated for all tinnitus patients with associated hearing difficulties 1

Sound therapy may be offered as a management option for symptomatic relief, though evidence is less conclusive than for CBT 1

Treatments to AVOID

The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against several commonly prescribed treatments:

• Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent tinnitus due to insufficient evidence and potential side effects 1
• Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements due to lack of consistent benefit 1

This is a critical pitfall to avoid—prescribing medications without clear evidence of benefit may cause side effects or worsen tinnitus 1

Special Populations Requiring Urgent Intervention

Patients with severe anxiety or depression:

• Require prompt identification and intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1
• While antidepressants are not recommended for tinnitus itself, treating underlying psychiatric conditions is essential 1

Patients with pulsatile tinnitus:

• Almost always require imaging evaluation (CTA or MRA) to identify potentially treatable vascular abnormalities 1, 3
• Treatable causes include arterial dissection (anticoagulation/antiplatelet therapy), sigmoid sinus diverticulum (surgical repair or endovascular embolization), and jugular bulb abnormalities (surgical intervention in symptomatic cases) 3

Patients with tinnitus relieved by neck pressure:

• Suggest vascular etiology requiring imaging with dedicated temporal bone CT as first-line, followed by CTA of head and neck 3
• May also indicate somatic tinnitus related to cervical dysfunction, which may benefit from physical therapy or manual therapy 3

Clinical Decision Points

Determine if tinnitus is bothersome versus non-bothersome, as this classification guides treatment intensity 1

Identify characteristics requiring imaging:

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

Obtain comprehensive audiologic examination for:

• Unilateral tinnitus 1
• Persistent tinnitus (≥6 months) 1
• Associated hearing difficulties 1

Key Pitfalls to Avoid

• Overlooking mild hearing loss that could benefit from hearing aid intervention 1
• Missing pulsatile tinnitus which requires vascular imaging to identify treatable abnormalities 4
• Failing to screen for psychiatric comorbidity given increased suicide risk 4
• Prescribing unproven supplements or medications that lack evidence and may cause harm 1