What are the management options for tinnitus?

Management of 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

Initial Evaluation and Risk Stratification

Determine if tinnitus is bothersome or non-bothersome, as this classification drives treatment intensity. 1, 2 Use validated questionnaires like the Tinnitus Handicap Inventory or Tinnitus Functional Index to quantify impact. 3

Classify tinnitus characteristics to identify red flags requiring imaging:

• Unilateral or asymmetric tinnitus → MRI with contrast mandatory to rule out vestibular schwannoma 3
• Pulsatile tinnitus → CTA or MRA required to identify vascular abnormalities 1
• Associated focal neurological deficits → imaging indicated 1
• Bilateral non-pulsatile tinnitus → imaging NOT routinely needed 1

Obtain comprehensive audiologic examination for all patients with unilateral tinnitus, persistent tinnitus (≥6 months), or any hearing difficulties. 1, 2, 3

Evidence-Based Treatment Algorithm

For ALL Patients with Persistent, Bothersome Tinnitus:

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

• Provide information about tinnitus mechanisms and natural progression 1, 2
• Discuss management strategies and realistic expectations 2

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

• Recommend hearing aids even for mild or unilateral hearing loss 1, 2, 3
• This is a strong recommendation as hearing loss is frequently associated with tinnitus and hearing aids provide significant relief 1, 4

3. Cognitive Behavioral Therapy

• CBT has the strongest evidence base for improving quality of life 1, 2, 3
• Should be offered to all patients with persistent, bothersome tinnitus 2
• The combination of sound therapy and CBT-based counseling has the strongest evidence 4

4. Sound Therapy (Adjunctive)

• May provide symptomatic relief for persistent tinnitus 1
• Wide-band sound therapy can be used alongside other interventions 4

Treatments to EXPLICITLY AVOID

Do NOT prescribe the following due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics (including benzodiazepines) for primary tinnitus treatment 1, 2, 3
• Dietary supplements including Ginkgo biloba, melatonin, or zinc 1, 2, 3
• Intratympanic medications 1, 2
• Transcranial Magnetic Stimulation (TMS) for routine treatment 2

Important Caveat:

While these medications should not be used to treat tinnitus itself, they may be appropriate for managing comorbid conditions like severe anxiety, depression, or sleep disturbance that accompany tinnitus. 5, 6 However, the primary indication is the psychiatric comorbidity, not the tinnitus.

Special Clinical Situations

Pulsatile Tinnitus:

• Almost always requires vascular imaging (CTA or MRA) 1
• Identify potentially treatable vascular abnormalities 1

Unilateral Tinnitus with Sudden Hearing Loss:

• Initiate urgent corticosteroid therapy 3
• Obtain MRI with contrast 3

Tinnitus with Severe Anxiety or Depression:

• Screen all patients with bothersome tinnitus for psychiatric comorbidities 1, 3
• Prompt intervention required due to increased suicide risk 1, 3

Chemotherapy-Induced Tinnitus:

• No causative treatment exists for established platinum-based ototoxicity 1
• Hearing aids remain beneficial 1
• CBT strategies can be offered with moderate evidence 1

Common Pitfalls to Avoid

• Do not overlook mild hearing loss that could benefit from hearing aid intervention 1, 3
• Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus 1
• Do not skip imaging for unilateral or pulsatile tinnitus as 10-15% have identifiable underlying causes 3
• Do not recommend supplements that lack evidence of efficacy 1, 2
• Do not assume bilateral tinnitus needs imaging unless other red flags present 1