What are the treatment options for tinnitus in adults?

Treatment of Tinnitus in Adults

For adults with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is the single most strongly recommended treatment based on the highest quality evidence, with hearing aids recommended for those with any degree of hearing loss (even mild or unilateral), while medications and dietary supplements should be avoided. 1, 2

Initial Evaluation to Guide Treatment

Before initiating treatment, determine whether the tinnitus requires urgent evaluation for underlying pathology:

• Obtain imaging studies (CTA or MRA) if: pulsatile tinnitus, unilateral tinnitus, focal neurological abnormalities, or asymmetric hearing loss are present 3
• Perform comprehensive audiologic examination for: unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 3
• Urgent psychiatric evaluation if: severe anxiety or depression accompanies tinnitus, as suicide risk is elevated in this population 1, 2, 4

Evidence-Based Treatment Algorithm

First-Line Treatments (Strong Evidence)

1. Cognitive Behavioral Therapy (CBT)

• CBT has the strongest evidence for improving quality of life and reducing tinnitus-related distress 2, 3
• This is the only treatment shown to have definite improvement in large randomized controlled trials 5
• CBT targets the psychological impact and habituation rather than eliminating the tinnitus sound itself 6, 7

2. Hearing Aids (for patients with hearing loss)

• Recommend hearing aid evaluation for ALL patients with tinnitus and hearing loss, even if hearing loss is only mild or unilateral 1, 2, 3
• Hearing aids address both hearing difficulties and tinnitus simultaneously 1
• This intervention has preponderance of benefit over harm 1

3. Sound Therapy

• May be recommended as adjunctive management for symptomatic relief 2, 3
• Works through three mechanisms: relieving tinnitus-associated stress, passively diverting attention, and actively diverting attention 2, 8
• Evidence is weaker than CBT, with limited data showing strong efficacy 9

4. Education and Counseling

• Provide education about tinnitus management strategies for all patients with persistent, bothersome tinnitus 3
• Set realistic expectations: goal is habituation and reduced distress, not complete elimination of tinnitus 2

Treatments to AVOID (Strong Recommendations Against)

Medications (Do NOT Routinely Recommend)

Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications should NOT be routinely recommended for primary treatment of tinnitus 1, 2, 3

• Insufficient evidence of efficacy despite some studies showing benefit 1
• Significant potential side effects, including paradoxical worsening of tinnitus 1
• Some medications (e.g., antidepressants) may actually worsen tinnitus 1
• Cost and false hope without proven benefit 1

Dietary Supplements (Do NOT Recommend)

Ginkgo biloba, melatonin, zinc, or other dietary supplements should NOT be recommended 1, 2, 3

• RCTs and systematic reviews show no consistent benefit 1, 2
• Commonly available but ineffective, leading to unnecessary expense and false hope 1

Acupuncture (No Recommendation)

• No recommendation can be made due to poor quality trials, no established benefit, and potential costs 1
• Serious harm from acupuncture is rare, but evidence is insufficient to support its use 1

Critical Clinical Pitfalls to Avoid

1. Missing treatable underlying causes:

• Pulsatile tinnitus almost always requires vascular imaging evaluation 2, 3
• Unilateral tinnitus warrants comprehensive audiologic examination and potentially imaging 2

2. Overlooking mild hearing loss:

• Even mild or unilateral hearing loss warrants hearing aid evaluation 2, 3
• Do not assume hearing loss must be severe to benefit from amplification 1

3. Ignoring psychiatric comorbidities:

• Patients with severe anxiety or depression require prompt professional intervention due to suicide risk 1, 2, 4
• This is a medical emergency that cannot be delayed 2

4. Pursuing expensive, unproven treatments:

• Avoid dietary supplements, transcranial magnetic stimulation (TMS), and other interventions lacking evidence 2
• These provide false hope while incurring significant costs 2

5. Setting unrealistic expectations:

• Approximately 80% of patients adapt to tinnitus over time without medical intervention 2
• The goal is habituation and reduced distress, not complete silence 2
• Only about 20% of adults with tinnitus require clinical intervention 1, 4

Special Populations

Chemotherapy-induced tinnitus:

• No causative treatment exists for established platinum-based chemotherapy ototoxicity 3
• Hearing aids remain beneficial 3
• CBT strategies can be offered with moderate evidence supporting effectiveness 3