What are the treatment options for tinnitus?

Treatment Options for 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 the cornerstone of management. 1

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, 2
• Assess if tinnitus is unilateral or bilateral – unilateral tinnitus warrants comprehensive audiologic examination and may require MRI of the internal auditory canal with contrast to exclude vestibular schwannoma 1, 3
• Identify if tinnitus is bothersome or non-bothersome – this distinction guides treatment intensity, as non-bothersome tinnitus may only require reassurance and education 1

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence)

• Cognitive Behavioral Therapy (CBT) should be recommended for all patients with persistent, bothersome tinnitus as it has the strongest evidence for improving quality of life 1, 4
• Hearing aids are recommended for patients with any degree of hearing loss and tinnitus, even if the hearing loss is mild or unilateral 1, 3
• Education and counseling about tinnitus management strategies are essential components for all patients with persistent tinnitus 1

Second-Line Treatments (Moderate Evidence)

• Sound therapy may be recommended as a management option for persistent tinnitus to provide symptomatic relief, though evidence is inconclusive 1, 4

Treatments to Address Specific Underlying Causes

• Vascular abnormalities (arterial dissection, sigmoid sinus diverticulum, jugular bulb abnormalities) may require surgical repair, endovascular embolization, or anticoagulation/antiplatelet therapy depending on the specific finding 2
• Somatic tinnitus related to cervical nerve or muscle dysfunction may benefit from physical therapy, postural adjustments, or manual therapy 2
• Eustachian tube dysfunction may respond to specific exercises or interventions targeting the tube 2

Treatments NOT Recommended

The following treatments should be avoided due to insufficient evidence and potential for harm:

• Antidepressants, anticonvulsants, or anxiolytics should not be routinely recommended for primary treatment of persistent tinnitus 1
• Intratympanic medications are not recommended for routine tinnitus management 1
• Dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements should not be recommended due to lack of consistent benefit 1

Critical Pitfalls to Avoid

• Do not overlook mild hearing loss – even mild or unilateral hearing loss warrants hearing aid evaluation, as this can provide significant relief 1
• Do not miss pulsatile tinnitus – this presentation requires vascular imaging to identify potentially treatable and dangerous vascular abnormalities 1, 2
• Do not delay psychiatric evaluation – patients with severe anxiety or depression require prompt identification and intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 3
• Do not prescribe medications without clear evidence – avoid prescribing medications that may cause side effects or worsen tinnitus without proven benefit 1

Special Considerations for Specific Presentations

• Tinnitus with dizziness/vertigo – consider Ménière's disease if accompanied by episodic vertigo lasting 20 minutes to 24 hours, fluctuating hearing loss, and aural fullness; treatment focuses on symptom management as there is no cure 3
• Tinnitus relieved by neck pressure – suggests vascular etiology requiring dedicated temporal bone CT and CTA of head and neck to evaluate for arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 2