Tinnitus Treatment Guidelines
Initial Evaluation and Classification
For patients with tinnitus, clinicians must first distinguish between bothersome and non-bothersome tinnitus, as this classification fundamentally determines whether active treatment is warranted. 1
Key Diagnostic Steps
Obtain a targeted history focusing on onset, duration, laterality (unilateral vs bilateral), quality (pulsatile vs non-pulsatile), pitch, loudness, pattern, and associated symptoms including hearing loss, vertigo, otalgia, otorrhea, or neurological deficits 2
Perform otoscopic examination to identify cerumen impaction, tympanic membrane abnormalities, or middle ear pathology 2
Conduct cranial nerve examination with particular attention to CN VIII (hearing) 2
Auscultate the neck, periauricular region, and temporal area for bruits if pulsatile tinnitus is reported 2
Distinguish persistent tinnitus (≥6 months) from recent onset to prioritize intervention and guide discussions about natural history 1, 2
Audiologic Testing
Obtain comprehensive audiologic examination promptly (within 4 weeks) for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1, 2
Consider routine audiologic examination for all tinnitus patients regardless of laterality, duration, or perceived hearing status, as hearing loss may be unrecognized 1, 2
Imaging Decisions
Do not obtain imaging studies unless one or more of the following red flags are present: 1, 2
- Unilateral or asymmetric tinnitus
- Pulsatile tinnitus
- Focal neurological abnormalities
- Asymmetric hearing loss
This recommendation is critical to avoid overutilization of low-yield testing while ensuring serious pathology (such as vestibular schwannoma or vascular abnormalities) is not missed. 1
Evidence-Based Treatment Algorithm
For Persistent, Bothersome Tinnitus
1. Education and Counseling (First-Line for All Patients)
- Provide education about tinnitus management strategies to all patients with persistent, bothersome tinnitus 1, 2, 3
2. Cognitive Behavioral Therapy (Strongest Evidence)
Recommend CBT for patients with persistent, bothersome tinnitus as it has the strongest evidence for improving quality of life 1, 3, 4, 5
CBT is the only treatment proven to improve quality of life outcomes in tinnitus patients 5
3. Hearing Aids (For Patients with Hearing Loss)
Recommend hearing aid evaluation for patients with hearing loss and persistent, bothersome tinnitus, even if hearing loss is mild or unilateral 1, 2, 3, 4
Hearing aids provide significant relief for patients with associated hearing loss 3
4. Sound Therapy (Optional)
- Clinicians may recommend sound therapy to patients with persistent, bothersome tinnitus, though evidence is less conclusive than for CBT 1, 3
Treatments NOT Recommended
Medications (Strong Recommendation Against Routine Use)
Do not routinely recommend the following medications for primary treatment of persistent, bothersome tinnitus: 1, 3, 4
- Antidepressants
- Anticonvulsants
- Anxiolytics
- Intratympanic medications
These medications lack sufficient evidence for efficacy and carry potential for side effects. 3
Dietary Supplements (Strong Recommendation Against)
Do not recommend dietary supplements including: 1, 3, 4
- Ginkgo biloba
- Melatonin
- Zinc
- Other dietary supplements
These lack consistent evidence of benefit for tinnitus treatment. 3
Other Interventions
Do not recommend transcranial magnetic stimulation (TMS) for routine treatment of persistent, bothersome tinnitus 1, 4
No recommendation can be made regarding acupuncture due to insufficient evidence 1, 4
Special Considerations
Pulsatile Tinnitus
- Pulsatile tinnitus almost always requires imaging evaluation (CTA or MRA) to identify potentially treatable vascular causes 3
Psychiatric Comorbidities
Promptly identify and intervene for patients with severe anxiety or depression due to increased suicide risk in tinnitus patients with psychiatric comorbidities 3
While antidepressants are not recommended for tinnitus itself, they may be appropriate for treating comorbid depression 5
Common Pitfalls to Avoid
Do not overlook mild hearing loss that could benefit from hearing aid intervention 2, 3
Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus 3
Do not obtain unnecessary imaging for non-pulsatile, bilateral tinnitus without neurological symptoms 2, 3
Do not recommend unproven treatments such as dietary supplements that lack efficacy evidence 2, 3