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 primary therapeutic intervention. 1, 2

Initial Evaluation Requirements

Before initiating treatment, clinicians must perform a targeted history and physical examination to identify potentially treatable underlying conditions that may relieve tinnitus. 3 Key elements to assess include:

• Tinnitus characteristics: Determine if pulsatile versus non-pulsatile, unilateral versus bilateral, and duration (persistent defined as ≥6 months). 1
• Associated symptoms: Hearing loss, vertigo, focal neurological deficits, or psychiatric comorbidities (anxiety/depression). 1
• Red flags requiring imaging: Unilateral tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss. 1

Obtain comprehensive audiologic examination for patients with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties. 1

Evidence-Based Treatment Algorithm

First-Line Interventions

1. Education and Counseling (for all patients with persistent, bothersome tinnitus)

   • Provide information about tinnitus mechanisms and natural progression. 1
   • Reassure patients that tinnitus is not life-threatening in most cases. 3
   • This foundational step is essential before implementing other therapies. 1

2. Hearing Aids (for patients with any degree of hearing loss)

   • Recommend hearing aid evaluation even if hearing loss is mild or unilateral. 1
   • Hearing aids provide significant relief for patients with associated hearing loss. 1
   • This applies to chemotherapy-induced tinnitus as well. 1

3. Cognitive Behavioral Therapy

   • CBT has the strongest evidence base for improving quality of life in tinnitus patients. 1, 2
   • Should be recommended for all patients with persistent, bothersome tinnitus. 1
   • Particularly important for patients with severe anxiety or depression, who have increased suicide risk. 1

4. Sound Therapy

   • May be recommended as a management option for symptomatic relief. 1
   • Evidence is less robust than for CBT but can provide benefit. 2

Treatments NOT Recommended

The following interventions should NOT be routinely recommended due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics (including benzodiazepines like clonazepam): Explicitly not recommended by the American Academy of Otolaryngology-Head and Neck Surgery for primary treatment of persistent tinnitus. 1, 4
• Intratympanic medications: Lack evidence for efficacy. 1
• Dietary supplements (Ginkgo biloba, melatonin, zinc): No consistent benefit demonstrated. 1

Special Considerations

Pulsatile Tinnitus:

• Almost always requires imaging evaluation (CTA or MRA) to identify potentially treatable vascular causes. 1, 5
• May indicate arteriovenous fistulas, arterial dissection, sigmoid sinus abnormalities, or jugular bulb abnormalities. 5
• Targeted treatment of identified vascular abnormalities is recommended. 5

Psychiatric Comorbidities:

• Patients with severe anxiety or depression require prompt identification and intervention due to increased suicide risk. 1
• While anxiolytics are not recommended for tinnitus itself, addressing psychiatric comorbidities through appropriate psychiatric care is essential. 4

Chemotherapy-Induced Tinnitus:

• No causative treatment exists for established ototoxicity. 1
• Hearing aids and CBT strategies remain beneficial. 1

Common Pitfalls to Avoid

• Do not prescribe medications without clear evidence of benefit, as they may cause side effects or worsen tinnitus. 1
• Do not overlook mild hearing loss that could benefit from hearing aid intervention. 1
• Do not recommend dietary supplements that lack evidence of efficacy. 1
• Do not obtain routine imaging unless red flags are present (unilateral, pulsatile, neurological deficits, or asymmetric hearing loss). 1