Management of Tinnitus
For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is the only treatment proven to improve quality of life and should be the cornerstone of management, combined with hearing aids for those with any degree of hearing loss. 1, 2
Initial Classification and Evaluation
Determine if tinnitus is bothersome or non-bothersome, as this fundamentally guides treatment intensity—non-bothersome tinnitus requires only reassurance and education, while bothersome tinnitus warrants active intervention. 1, 2
Classify tinnitus characteristics systematically:
- Pulsatile vs. non-pulsatile: Pulsatile tinnitus almost always requires imaging (CTA or MRA) to identify vascular abnormalities or treatable causes. 1
- Unilateral vs. bilateral: Unilateral tinnitus requires comprehensive audiologic examination and consideration of imaging to rule out vestibular schwannoma or other focal pathology. 1, 3
- Duration: Persistent tinnitus (≥6 months) versus recent onset guides urgency and treatment approach. 2, 3
Obtain comprehensive audiologic examination for any patient with unilateral tinnitus, persistent tinnitus, or self-reported hearing difficulties—do not rely on patient perception alone, as mild hearing loss is frequently overlooked. 1, 2, 3
Imaging is NOT indicated for bilateral, non-pulsatile tinnitus without neurological symptoms or asymmetric hearing loss—this is a common pitfall that leads to unnecessary testing and cost. 1, 3
Evidence-Based Treatment Algorithm
First-Line Interventions (All Patients with Persistent, Bothersome Tinnitus)
1. Education and Counseling (Universal) Provide all patients with structured education about tinnitus mechanisms, natural history, and management strategies—this alone can reduce distress and is essential groundwork for other interventions. 1, 2
2. Hearing Aid Evaluation (If Any Hearing Loss Present) Recommend hearing aids even for mild or unilateral hearing loss—this is strongly supported by guidelines and provides significant symptomatic relief, as most tinnitus is associated with sensorineural hearing loss. 1, 2, 4 The American Academy of Otolaryngology-Head and Neck Surgery specifically emphasizes not overlooking mild hearing loss that could benefit from amplification. 1, 2
3. Cognitive Behavioral Therapy (Primary Treatment) CBT has the strongest evidence base for improving quality of life in tinnitus patients and should be recommended for all patients with persistent, bothersome tinnitus. 1, 2, 4 This is the only intervention with randomized controlled trial evidence showing preponderance of benefit over harm. 2
Adjunctive Options (May Consider)
Sound therapy may be offered as a management option for symptomatic relief, though evidence is less robust than for CBT. 1, 5 The strongest evidence supports combining sound therapy with CBT-based counseling rather than using sound therapy alone. 4
Treatments NOT Recommended
Do NOT prescribe medications including antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment—these lack evidence of benefit and carry risk of side effects. 1, 2 The only exception is treating comorbid psychiatric conditions (depression, anxiety) as separate diagnoses, not as tinnitus treatment. 1
Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc—these lack consistent evidence of efficacy despite widespread use. 1, 2
Do NOT recommend transcranial magnetic stimulation (TMS) for routine tinnitus treatment. 2
Insufficient evidence exists for acupuncture—the American Academy of Otolaryngology-Head and Neck Surgery found inadequate data to recommend for or against this intervention. 2
Special Populations and Situations
Pulsatile tinnitus requires vascular imaging (CTA or MRA) to identify potentially treatable vascular abnormalities or masses—this is non-negotiable. 1
Screen for severe anxiety or depression and intervene promptly, as tinnitus patients with psychiatric comorbidities have increased suicide risk. 1
For chemotherapy-induced tinnitus (platinum-based agents), no causative treatment exists for established ototoxicity, but hearing aids and CBT remain beneficial. 1
Common Pitfalls to Avoid
- Overlooking mild or unilateral hearing loss that would benefit from hearing aid intervention—always obtain objective audiometry rather than relying on patient report. 1, 3
- Ordering imaging for bilateral non-pulsatile tinnitus without red flags—this wastes resources and does not change management. 1, 3
- Prescribing unproven medications or supplements that may worsen tinnitus or cause side effects without evidence of benefit. 1, 2
- Failing to distinguish bothersome from non-bothersome tinnitus—treatment intensity should match symptom burden. 1, 2