What are the treatment options for tinnitus?

Treatment for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence for improving quality of life in patients with persistent, bothersome tinnitus and should be offered to all such patients. 1, 2, 3

Initial Classification and Evaluation

Before initiating treatment, classify the tinnitus to identify potentially treatable underlying causes:

• Determine if tinnitus is pulsatile or non-pulsatile – pulsatile tinnitus almost always requires imaging evaluation (CTA or MRA) to identify vascular abnormalities 1, 3
• Assess if tinnitus is unilateral or bilateral – unilateral tinnitus is a red flag mandating MRI with contrast to rule out vestibular schwannoma or other structural pathology 3
• Distinguish bothersome from non-bothersome tinnitus using validated questionnaires (Tinnitus Handicap Inventory or Tinnitus Functional Index), as this determines whether active treatment is needed 2, 3
• Obtain comprehensive audiologic examination for all patients with unilateral tinnitus, persistent tinnitus (≥6 months), or hearing difficulties 1, 2, 3

Evidence-Based Treatment Algorithm

For Patients With Hearing Loss (Even Mild or Unilateral):

• Recommend hearing aid evaluation immediately – hearing aids provide significant relief and are indicated even for mild or unilateral hearing loss 1, 2, 3
• Hearing aids address the auditory deprivation that contributes to tinnitus generation and can provide substantial benefit 1, 2

For All Patients With Persistent, Bothersome Tinnitus:

• Provide education and counseling about tinnitus management strategies as an essential component for all patients 1, 2
• Offer Cognitive Behavioral Therapy (CBT) – this has the strongest evidence from randomized controlled trials showing preponderance of benefit over harm for improving quality of life 1, 2, 3, 4
• Consider sound therapy as a management option for symptomatic relief, which can involve soothing sound for stress relief, background sound to reduce contrast with tinnitus, or interesting sound to actively divert attention 1, 5, 6

Special Populations:

• For chemotherapy-induced tinnitus: No causative treatment exists for established ototoxicity, but hearing aids and CBT strategies remain beneficial 1
• For sudden hearing loss with tinnitus: Initiate urgent corticosteroid therapy 3

Treatments to Explicitly AVOID

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

• Do NOT prescribe antidepressants, anticonvulsants, anxiolytics (including benzodiazepines), or intratympanic medications for primary tinnitus treatment 1, 2, 3
• Do NOT recommend dietary supplements including Ginkgo biloba, melatonin, or zinc – these lack consistent benefit 1, 2, 3
• Do NOT recommend Transcranial Magnetic Stimulation (TMS) for routine tinnitus treatment 2
• Avoid prescribing medications without clear evidence that may cause side effects or worsen tinnitus 1

Critical Safety Considerations

• Screen all patients with bothersome tinnitus for anxiety and depression – psychiatric comorbidities increase suicide risk and require prompt intervention 1, 3
• Never overlook mild hearing loss that could benefit from hearing aid intervention, as this is a common pitfall 1
• If imaging reveals vestibular schwannoma or structural pathology, refer immediately to neurotology/neurosurgery for definitive management 3

Treatment Hierarchy Based on Evidence Quality

The strength of evidence varies significantly across interventions. CBT stands alone as having definitive benefit from large randomized controlled trials 2, 4. Hearing aids have strong supporting evidence for patients with associated hearing loss 1, 2. Sound therapy has moderate evidence when combined with education and counseling 1, 5. Acupuncture has insufficient evidence to make any recommendation 2.