What treatment options are available for individuals with sensitivity to certain sounds, also known as hyperacusis or misophonia?

Treatment for Sound Sensitivity (Hyperacusis and Misophonia)

For individuals with sound sensitivity, treatment should begin with differential diagnosis through detailed history and audiometry to distinguish hyperacusis (physical discomfort from loud sounds) from misophonia (emotional reactions to specific trigger sounds), followed by sound desensitization therapy combined with retraining counseling as the primary evidence-based intervention. 1, 2, 3

Differential Diagnosis is Essential

Before initiating treatment, you must distinguish between the two main types of sound sensitivity, as they have different underlying mechanisms and treatment implications:

Hyperacusis Assessment

• Measure uncomfortable loudness levels (ULLs) during pure-tone audiometry—hyperacusis patients typically show markedly decreased ULLs, usually less than 90 dB HL 4
• Look for physical pain or discomfort when any sound reaches a certain loudness level that would be tolerable for most people 1
• Note that 86% of hyperacusis patients also have tinnitus, and exposure to loud sounds worsens their condition temporarily 4
• Hyperacusis patients often report headaches and that sounds are frequently painful 4
• Pure-tone audiograms typically show normal hearing or slight high-tone loss 4

Misophonia Assessment

• Identify specific trigger sounds (most commonly body sounds like chewing, sniffing, breathing) that provoke intense emotional reactions regardless of loudness 1, 2
• Use the Misophonia Questionnaire to assess severity and monitor treatment progress 2
• Recognize that emotional reactions depend on the pattern and meaning of sounds, not their physical characteristics—patients can tolerate other sounds at higher levels than their trigger sounds 3
• Note that reactions often depend on who produces the sound or the situation in which it occurs 3
• ULLs may be relatively high in misophonia patients who are hypersensitive to specific sounds, distinguishing them from hyperacusis 4

Key Diagnostic Pitfall

The Hyperacusis Questionnaire (HQ) was developed before misophonia was recognized and contains items that correlate with both conditions—some items reflect social impact (more related to misophonia) while others reflect concentration difficulties in noise (more related to hyperacusis) 5. Therefore, do not rely solely on the HQ to differentiate these conditions 5.

Primary Treatment: Sound Desensitization and Retraining Counseling

Core Treatment Approach

Treatment generally involves gradual and systematic sound desensitization combined with counseling, which has shown an 83% success rate over 20 years of clinical use 1, 3

Specific Treatment Components for Misophonia

Retraining Counseling

• Explain the neurophysiological model: Misophonia results from conditioned reflexes linking the auditory system with the limbic and autonomic nervous systems—these are subconscious connections that patients cannot consciously control 3
• Emphasize that the auditory pathways themselves function normally; the problem lies in the strength of functional connections between brain systems 3
• Help patients understand that their emotional reactions are disproportionate but involuntary, reducing self-blame and anxiety 3

Desensitization and Habituation Therapy

• Focus on extinction of conditioned reflexes linking auditory input to emotional/physiological responses 3
• Implement gradual, systematic exposure to trigger sounds in controlled settings 2
• Use sound therapy as part of the desensitization protocol 3
• Monitor progress with the Misophonia Questionnaire at regular intervals to track decreasing severity 2

Treatment for Hyperacusis

• Apply the same principles of sound desensitization and counseling used for misophonia 1
• Gradually increase exposure to sounds at tolerable levels, systematically expanding the range of comfortable loudness 1
• Provide counseling about the mechanisms of decreased sound tolerance 1

Important Clinical Considerations

Comorbidities and Overlap

• Many patients have both hyperacusis and misophonia—assess for both conditions separately 5
• Physiological and emotional reactions are identical for both conditions, so reactions alone cannot differentiate them 3
• A single-item question about hyperacusis presence can reliably identify hyperacusis characteristics, even when reassessed 18 months later 5

Patient Demographics

• Hyperacusis patients are typically younger than tinnitus or noise-induced hearing loss patients (mean age approximately 10 years less) 4
• Hyperacusis is rarely caused by occupational noise exposure (except music exposure) 4

Avoid These Pitfalls

• Do not assume all sound sensitivity is hyperacusis—misophonia requires different conceptualization and may need different emphasis in treatment 1, 3
• Do not use loudness-based interventions alone for misophonia—the trigger is the pattern and meaning, not the volume 3
• Ensure all healthcare professionals involved use consistent terminology so treatment goals remain aligned 1

Treatment Timeline

• Administer the Misophonia Questionnaire at regular intervals to objectively track improvement 2
• Treatment success is defined by decreased severity scores and improved quality of life 2
• The 83% success rate reported for the neurophysiological approach represents outcomes over extended treatment periods 3