Management of Tinnitus
For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) is the only treatment with strong evidence for improving 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 guides treatment intensity—non-bothersome tinnitus requires only reassurance and education, while bothersome tinnitus warrants active intervention. 1, 2
Classify tinnitus as pulsatile versus non-pulsatile, since pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) to identify treatable vascular abnormalities, whereas bilateral non-pulsatile tinnitus typically does not need imaging. 1, 3
Obtain comprehensive audiologic examination for any patient with unilateral tinnitus, persistent tinnitus (≥6 months), or any perceived hearing difficulty—this identifies even mild hearing loss that benefits from amplification. 1, 2, 3
Reserve imaging studies exclusively for patients with unilateral/asymmetric tinnitus, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss—routine imaging for bilateral non-pulsatile tinnitus wastes resources. 1, 3
Evidence-Based Treatment Algorithm
First-Line Interventions (All Patients with Persistent, Bothersome Tinnitus)
Provide education and counseling about tinnitus mechanisms and management strategies to all patients—this foundational step reduces anxiety and sets realistic expectations. 1, 2
Recommend hearing aid evaluation for any patient with documented hearing loss, even if mild or unilateral—hearing aids provide significant symptomatic relief by amplifying environmental sounds that mask tinnitus. 1, 2, 4
Refer for cognitive behavioral therapy (CBT), which has the strongest evidence base among all tinnitus treatments for improving quality of life through restructuring maladaptive thought patterns and reducing distress. 1, 2, 4
Consider sound therapy as an adjunctive option for symptomatic relief, though evidence is less robust than for CBT—sound enrichment can provide masking and habituation. 1
Treatments to Avoid
Do not prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment—these lack consistent evidence of benefit and carry significant side effect risks. 1, 2
Do not recommend dietary supplements including Ginkgo biloba, melatonin, or zinc—no supplement has demonstrated consistent benefit in rigorous trials. 1, 2
Do not recommend transcranial magnetic stimulation (TMS) for routine tinnitus treatment due to insufficient evidence. 2
Special Populations and Situations
Screen for severe anxiety or depression and provide prompt psychiatric intervention when present—tinnitus patients with psychiatric comorbidities have increased suicide risk requiring urgent attention. 1
For chemotherapy-induced tinnitus from platinum agents, no causative treatment exists for established ototoxicity, but hearing aids and CBT strategies remain beneficial for symptom management. 1
Common Pitfalls to Avoid
Do not overlook mild or unilateral hearing loss—even minimal hearing impairment benefits from amplification, and this is frequently missed when patients don't perceive significant hearing difficulty. 1, 3
Do not order imaging for bilateral non-pulsatile tinnitus without neurological findings—this represents unnecessary healthcare expenditure without diagnostic yield. 1, 3
Do not prescribe medications or supplements without evidence—the temptation to "do something" often leads to ineffective treatments with potential harm. 1, 2