What are the treatment options for tinnitus?

Treatment of 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 imaging (CTA or MRA) to exclude vascular abnormalities such as arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 1, 2
• Assess if tinnitus is unilateral or bilateral – unilateral or asymmetric tinnitus requires MRI of internal auditory canals with contrast to exclude vestibular schwannoma 3
• Perform otoscopy to exclude cerumen impaction, middle ear infection, or retrotympanic masses 1, 3
• Obtain comprehensive audiologic examination for any tinnitus that is unilateral, persistent ≥6 months, or associated with hearing difficulties 1

Critical pitfall: Do NOT obtain imaging for bilateral, symmetric, non-pulsatile tinnitus without focal neurologic abnormalities or asymmetric hearing loss 1, 3

Evidence-Based Treatment Algorithm

First-Line Treatments

1. Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life and should be recommended for all patients with persistent, bothersome tinnitus 1, 3
• This is the only intervention proven effective in large randomized controlled trials 4, 5

2. Hearing Aids

• Recommend hearing aid evaluation for ANY degree of hearing loss, even if mild or unilateral 1, 3
• Hearing aids provide significant relief for patients with associated hearing loss and should not be withheld based on severity 1, 6

3. Education and Counseling

• Provide education about tinnitus management strategies for all patients with persistent, bothersome tinnitus 1
• Reassure patients that tinnitus is not life-threatening in most cases 1

4. Sound Therapy

• May be recommended as a management option for symptomatic relief, though evidence is less robust than for CBT 1, 6

Treatments to AVOID

Do NOT routinely recommend the following due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment 1, 3
• Intratympanic medications 1, 3
• Dietary supplements including Ginkgo biloba, melatonin, zinc, or other supplements 1, 2
• Antiviral medications 3

Critical pitfall: Prescribing medications without clear evidence may cause side effects or worsen tinnitus 1

Special Populations and Circumstances

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids remain beneficial 1
• CBT strategies can be offered with moderate supporting evidence 1

Psychiatric Comorbidities

• Promptly identify and intervene for patients with severe anxiety or depression due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 2, 3
• While antidepressants are not recommended for primary tinnitus treatment, they may be appropriate for treating comorbid depression itself 5

Somatic Tinnitus (Relieved by Neck Pressure)

• Consider physical therapy, postural adjustments, or manual therapy for cervical nerve or muscle dysfunction 2
• Evaluate for Eustachian tube dysfunction that may respond to specific exercises 2

Key Clinical Pearls

• No cure exists for tinnitus – treatment focuses on symptom management and quality of life improvement 3
• The majority of patients (approximately 80%) adapt to tinnitus without requiring intensive intervention 4
• Avoid noise exposure to prevent development or progression of tinnitus 5
• Do not overlook mild hearing loss that could benefit from hearing aid intervention 1