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 recommended as first-line therapy. 1
Evidence-Based Treatment Algorithm
First-Line Interventions
CBT should be offered to all patients with persistent, bothersome tinnitus as it has the most robust evidence for improving quality of life outcomes. 1, 2
Hearing aids must be recommended for any patient with tinnitus and associated hearing loss, even if the hearing loss is mild or unilateral. 1 This intervention provides significant symptomatic relief and addresses the underlying auditory dysfunction. 1
Education and counseling are essential components for all patients with persistent tinnitus and should be provided at the initial evaluation to help patients understand the condition and management strategies. 1
Sound Therapy Options
Sound therapy may be offered as a management option for symptomatic relief in patients with persistent tinnitus. 1
Masking devices can provide relief for some patients, though evidence is less robust than for CBT. 3
Special Populations and Circumstances
For pulsatile tinnitus:
- Vascular imaging (CTA or MRA) is mandatory to identify potentially treatable vascular abnormalities such as arterial dissection, sigmoid sinus abnormalities, or arteriovenous malformations. 4, 2
- Treatment targets the specific underlying vascular cause once identified. 4
For unilateral or asymmetric tinnitus:
- MRI of internal auditory canals with contrast is required to exclude vestibular schwannoma. 2
For chemotherapy-induced tinnitus:
- No causative treatment exists for established platinum-based chemotherapy ototoxicity. 1
- Hearing aids and CBT strategies remain the primary management options. 1
Treatments NOT Recommended
The following interventions should NOT be routinely used due to insufficient evidence and potential harm:
Antidepressants, anticonvulsants, and anxiolytics should not be prescribed for primary tinnitus treatment unless treating comorbid psychiatric conditions. 1, 2
Intratympanic medications are not recommended for persistent, bothersome tinnitus. 1
Dietary supplements including Ginkgo biloba, melatonin, and zinc should not be recommended due to lack of consistent benefit. 1, 4
Antiviral medications are not indicated for tinnitus treatment. 2
Critical Clinical Considerations
Psychiatric screening is mandatory:
- Patients with severe anxiety or depression require prompt psychiatric intervention due to significantly increased suicide risk in tinnitus patients with psychiatric comorbidities. 1, 4, 2
Imaging is NOT indicated for:
- Bilateral, symmetric, non-pulsatile tinnitus without focal neurologic findings or asymmetric hearing loss. 2
Imaging IS required for:
- Pulsatile tinnitus (vascular imaging). 4, 2
- Unilateral or asymmetric tinnitus (MRI with contrast). 2
- Focal neurologic abnormalities. 1
- Asymmetric hearing loss. 1
Common Pitfalls to Avoid
Do not overlook mild hearing loss that could benefit from hearing aid intervention, as even mild or unilateral hearing loss warrants hearing aid evaluation. 1, 4
Do not prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus. 1
Do not tell patients "nothing can be done" as this is inappropriate and multiple evidence-based management strategies exist. 3
Do not skip comprehensive audiologic examination for tinnitus that is unilateral, persistent ≥6 months, or associated with hearing difficulties. 1, 2