What are the treatment options for tinnitus?

Treatment of Tinnitus

Cognitive Behavioral Therapy (CBT) is the single most evidence-based treatment for improving quality of life in patients with persistent, bothersome tinnitus, and should be offered to all such patients. 1, 2, 3

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 identify vascular abnormalities that may be treatable 1
• Assess if tinnitus is unilateral or bilateral – unilateral tinnitus warrants imaging studies and comprehensive audiologic examination to rule out vestibular schwannoma or asymmetric pathology 1, 3
• Distinguish bothersome from non-bothersome tinnitus – only bothersome tinnitus requires active intervention beyond reassurance 1, 3
• Obtain comprehensive audiologic examination for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1, 3

Evidence-Based Treatment Algorithm

For ALL Patients with Persistent, Bothersome Tinnitus:

1. Provide education and counseling about tinnitus mechanisms and management strategies as a foundational element 1, 2, 3

2. Recommend CBT – this structured intervention includes cognitive restructuring, applied relaxation, behavioral activation, and positive mental imagery, typically delivered over 8 weekly sessions of approximately 120 minutes each 2, 3

   • CBT works equally well regardless of initial tinnitus severity, duration, or presence of hearing loss 2
   • This is the only treatment with robust evidence for improving quality of life 1, 3, 4

For Patients with Hearing Loss (Even Mild or Unilateral):

• Recommend hearing aid evaluation and fitting – hearing aids provide significant relief and should be combined with CBT when both hearing loss and bothersome tinnitus are present 1, 2, 3
• Do not withhold hearing aids based on mild severity or unilateral presentation 1, 3

For Patients with Severe Anxiety or Depression:

• Promptly identify and intervene due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1
• Refer for appropriate psychiatric care while continuing tinnitus-specific CBT 1

Treatments That Should NOT Be Recommended

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

• Antidepressants, anticonvulsants, or anxiolytics – these medications lack evidence for primary tinnitus treatment and may cause side effects 1, 3
• Intratympanic medications – no evidence supports their use for persistent tinnitus 1, 3
• Dietary supplements including Ginkgo biloba, melatonin, or zinc – these lack consistent benefit 1, 3
• Transcranial Magnetic Stimulation (TMS) – should not be used for routine tinnitus treatment 3

Sound Therapy Considerations

• Sound therapy may be offered as a management option for symptomatic relief, though evidence is less robust than for CBT 1
• Sound therapy works best when combined with CBT-based counseling rather than as monotherapy 5

Common Pitfalls to Avoid

• Do not overlook mild or unilateral hearing loss – these patients still benefit from hearing aid intervention 1, 3
• Do not prescribe medications without clear evidence – this exposes patients to side effects without proven benefit 1, 3
• Do not obtain imaging studies for bilateral, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss 1, 3
• Do not combine CBT with antidepressants or anxiolytics as primary tinnitus treatment, as these medications lack evidence for tinnitus specifically 2

Special Population: Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 1
• Hearing aids and CBT strategies remain beneficial for these patients 1
• Sodium thiosulfate may be considered for prevention in children receiving cisplatin, but evidence in adults is uncertain 1