What are the treatment options for tinnitus?

Treatment Options for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment proven to improve quality of life in patients with persistent, bothersome tinnitus and should be your primary therapeutic recommendation. 1

Initial Evaluation and Classification

Before initiating treatment, you must distinguish between pulsatile and non-pulsatile tinnitus, as this fundamentally changes your management approach:

• Pulsatile tinnitus requires imaging evaluation in nearly all cases (CT temporal bone or CTA head/neck) because over 70% have identifiable vascular or structural causes, including life-threatening conditions like dural arteriovenous fistulas or arterial dissection 2
• Non-pulsatile, bilateral tinnitus without focal neurologic deficits does not require imaging 1, 3
• Perform otoscopy immediately to exclude simple treatable causes like cerumen impaction, retrotympanic masses, or middle ear infection 3
• Obtain comprehensive audiometry for any unilateral tinnitus, persistent tinnitus (≥6 months), or tinnitus with hearing difficulties 1

Evidence-Based Treatment Algorithm

For All Patients with Persistent, Bothersome Tinnitus:

1. Education and Counseling (First-Line for Everyone)

• Provide education about tinnitus mechanisms and natural progression to all patients 1
• This is an essential component that should never be skipped 1

2. Hearing Aid Evaluation (If Any Hearing Loss Present)

• Recommend hearing aids even for mild or unilateral hearing loss 1
• This is strongly recommended by the American Academy of Otolaryngology-Head and Neck Surgery and provides significant relief 1, 4
• Do not overlook mild hearing loss—this is a common pitfall 1

3. Cognitive Behavioral Therapy

• CBT has the strongest evidence for improving quality of life and should be offered to patients with persistent, bothersome tinnitus 1, 4
• The combination of sound therapy and CBT-based counseling has the strongest evidence base 4

4. Sound Therapy

• May be recommended as a management option for symptomatic relief 1
• Wide-band sound therapy can be used in combination with CBT 4

Treatments You Should NOT Recommend

The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against the following due to insufficient evidence and potential harm:

• Do not prescribe antidepressants, anticonvulsants, or anxiolytics for primary treatment of tinnitus 1
• Do not prescribe intratympanic medications 1
• Do not recommend dietary supplements including Ginkgo biloba, melatonin, or zinc—these lack consistent benefit 1

Exception for Psychiatric Comorbidity:

• If severe anxiety or depression is present, provide immediate psychiatric intervention due to increased suicide risk in tinnitus patients with psychiatric comorbidities 1, 3
• In this context, treating the underlying psychiatric condition is appropriate, but not as primary tinnitus treatment 4

Special Considerations

Pulsatile Tinnitus:

• Order high-resolution CT temporal bone (non-contrast) for suspected paragangliomas, glomus tumors, jugular bulb abnormalities, or superior semicircular canal dehiscence 2
• Order CTA head/neck with contrast for suspected dural AVF, arterial dissection, atherosclerotic carotid disease, or sigmoid sinus abnormalities 2
• Missing dural AVF is life-threatening—maintain high index of suspicion 2

Unilateral Tinnitus:

• Requires MRI internal auditory canals with contrast to exclude vestibular schwannoma 3
• Always obtain comprehensive audiometry 1

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

Common Pitfalls to Avoid

• Failing to perform otoscopy before ordering expensive imaging studies 3
• Ordering brain imaging for bilateral, symmetric, non-pulsatile tinnitus without neurological deficit—this is unnecessary and wasteful 3
• Dismissing pulsatile tinnitus as benign—this almost always requires imaging 2, 3
• Prescribing medications without evidence that may cause side effects or worsen tinnitus 1
• Overlooking mild hearing loss that could benefit from hearing aid intervention 1