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 recommended as first-line therapy. 1, 2

Initial Evaluation Framework

Before initiating treatment, classify tinnitus characteristics to identify potentially treatable underlying conditions:

• Determine if tinnitus is pulsatile or non-pulsatile – pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) to exclude treatable vascular abnormalities 1, 2
• Assess laterality – unilateral or asymmetric tinnitus requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma 2
• Perform comprehensive audiologic examination for tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties 1, 2
• Screen for severe anxiety or depression – these patients require prompt psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 3

Evidence-Based Treatment Algorithm

For All Patients with Persistent, Bothersome Tinnitus:

• Provide education and counseling about tinnitus management strategies as an essential first step 1
• Recommend CBT – this has the strongest evidence base for improving quality of life and should be offered to all patients with persistent, bothersome tinnitus 1, 3, 2

For Patients with Associated Hearing Loss:

• Recommend hearing aid evaluation even if hearing loss is mild or unilateral – hearing aids provide significant relief and are strongly recommended 1, 3, 4
• Consider sound therapy as a management option for symptomatic relief, though evidence is less robust than for CBT 1

For Specific Tinnitus Subtypes:

• Pulsatile tinnitus relieved by neck pressure – obtain CTA or MRA to identify vascular abnormalities (arterial dissection, sigmoid sinus diverticulum, jugular bulb abnormalities) that may require surgical or endovascular intervention 3
• Somatic tinnitus related to cervical dysfunction – physical therapy, postural adjustments, or manual therapy may provide benefit 3
• Chemotherapy-induced tinnitus – no causative treatment exists for established ototoxicity; focus on hearing aids and CBT strategies 1

Treatments NOT Recommended

Avoid the following interventions due to insufficient evidence and potential harm:

• Do NOT routinely prescribe antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment 1, 2
• Do NOT recommend intratympanic medications for persistent tinnitus 1, 2
• Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc due to lack of consistent benefit 1, 3

Critical Clinical Pitfalls to Avoid

• Do not obtain imaging for bilateral, symmetric, non-pulsatile tinnitus – imaging is only indicated for unilateral, pulsatile, or neurologically abnormal presentations 2
• Do not overlook mild hearing loss – even mild or unilateral hearing loss warrants hearing aid evaluation 1, 3
• Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus 1
• Do not miss psychiatric comorbidities – failure to identify severe anxiety or depression increases suicide risk 1, 3

Treatment Expectations

• No cure exists for tinnitus – treatment focuses on symptom management and quality of life improvement 2
• The combination of sound therapy and CBT-based counseling has the strongest evidence base, though clinical trials are constrained by patient heterogeneity 4
• Degree of patient distress should guide treatment intensity – patients with minimal bother may only need reassurance and education 1