Medication-Induced Tinnitus Management
Reduce the Wellbutrin (bupropion) dose from 300mg back to the previous lower dose or discontinue it entirely, as the temporal relationship strongly suggests medication-induced tinnitus, and the American Academy of Otolaryngology-Head and Neck Surgery explicitly warns that antidepressants can worsen tinnitus. 1
Immediate Next Steps
Medication Review and Adjustment
- Decrease or discontinue Wellbutrin first, given the patient's clear temporal association between the 300mg dose increase and worsening tinnitus 1
- The FDA label for bupropion does not list tinnitus as a common adverse effect, but clinical guidelines specifically warn that antidepressants may worsen tinnitus 2
- If discontinuing Wellbutrin 300mg, taper to 150mg once daily before complete discontinuation per FDA recommendations 2
Evaluate Prozac (Fluoxetine) Contribution
- Consider reducing or discontinuing Prozac (fluoxetine) 50mg as well, since SSRIs including fluoxetine have documented associations with tinnitus development 3, 4
- Research demonstrates that sertraline (another SSRI similar to fluoxetine) can cause bilateral tinnitus that resolves completely after medication discontinuation 3
- The American Academy of Otolaryngology-Head and Neck Surgery guidelines state that antidepressants should not be routinely recommended for tinnitus treatment due to potential for worsening symptoms 1
Clinical Assessment Required
Characterize the Tinnitus
- Determine if tinnitus is unilateral or bilateral, pulsatile or non-pulsatile 1
- Unilateral, pulsatile tinnitus, focal neurological abnormalities, or asymmetric hearing loss warrant imaging studies 1, 5
- Bilateral non-pulsatile tinnitus without these features does not require imaging 1, 5
Audiometric Evaluation
- Obtain comprehensive audiologic examination if tinnitus is unilateral, persistent (≥6 months), or associated with hearing difficulties 5
- Hearing aid evaluation should be recommended if hearing loss is present, as hearing aids can improve tinnitus even with mild or unilateral hearing loss 1, 5
Screen for Psychiatric Comorbidity
- Assess for severe anxiety or depression requiring prompt intervention, as suicide risk is elevated in tinnitus patients with psychiatric illness 1
- This is particularly important given the patient is already on two psychiatric medications 1
Evidence-Based Treatment Options After Medication Adjustment
First-Line Non-Pharmacologic Interventions
- Cognitive Behavioral Therapy (CBT) has the strongest evidence for improving quality of life in persistent, bothersome tinnitus 1, 5
- Education and counseling about tinnitus management strategies should be provided to all patients 1, 5
- Sound therapy may be recommended for symptomatic relief 1, 5
Treatments to Avoid
- Do not add additional antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment, as evidence shows insufficient benefit with potential for harm including worsening tinnitus 1, 5
- Avoid dietary supplements (Ginkgo biloba, melatonin, zinc) as they lack evidence of efficacy 1, 5
Critical Pitfalls to Avoid
- Do not continue both medications at current doses while waiting to see if tinnitus improves spontaneously, as medication-induced tinnitus may persist or worsen 1, 3
- Do not add another medication to treat the tinnitus without first addressing the likely causative agents 1
- Do not dismiss the patient's temporal correlation between dose increase and symptom worsening—this is clinically significant 3
- Research shows bupropion 150mg does not enhance tinnitus treatment and should not be used for this indication 6
Expected Timeline
- Tinnitus from SSRI discontinuation typically resolves completely within days to weeks after stopping the offending medication 3
- Monitor for 2-4 weeks after medication adjustment to assess symptom resolution 3
- If tinnitus persists after medication discontinuation, proceed with comprehensive audiologic evaluation and consider CBT 1, 5