What are the treatment options for tinnitus?

Tinnitus Treatment

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 your primary therapeutic recommendation. 1

Initial Classification and Evaluation

Classify tinnitus as either pulsatile or non-pulsatile, and determine if it is bothersome or non-bothersome, as this drives your entire management approach 1:

• Pulsatile tinnitus almost always requires vascular imaging (CTA or MRA) to identify treatable vascular abnormalities like arteriovenous fistulas, arterial dissection, or sigmoid sinus abnormalities 2
• Unilateral or asymmetric tinnitus warrants audiologic evaluation and potentially MRI with contrast to exclude vestibular schwannoma 3
• Bilateral non-pulsatile tinnitus typically does not require imaging unless focal neurological abnormalities or asymmetric hearing loss are present 1

Obtain comprehensive audiometry for any patient with unilateral tinnitus, persistent symptoms ≥6 months, or hearing difficulties 1.

Evidence-Based Treatment Algorithm

For Patients With Hearing Loss (Even Mild or Unilateral)

Recommend hearing aids as first-line intervention - this provides significant relief even when hearing loss is mild or affects only one ear 1. This is a common pitfall: clinicians often overlook mild hearing loss that could benefit from amplification 1.

For All Patients With Persistent, Bothersome Tinnitus

Provide three core interventions 1:

1. Education and counseling about tinnitus mechanisms and management strategies
2. Cognitive Behavioral Therapy (CBT) - the strongest evidence-based treatment for improving quality of life
3. Sound therapy as an adjunctive option for symptomatic relief 1

Special Populations

For patients with dizziness and tinnitus, consider Ménière's disease if vertigo episodes last 20 minutes to 24 hours with fluctuating hearing loss and aural fullness 3. These patients still benefit from CBT and hearing aids for the tinnitus component 3.

For chemotherapy-induced tinnitus from platinum agents, no causative treatment exists for established ototoxicity, but hearing aids and CBT remain beneficial 1.

What NOT to Recommend

Do not routinely prescribe the following due to insufficient evidence and potential side effects 1:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment
• Dietary supplements including Ginkgo biloba, melatonin, or zinc
• Intratympanic medications

This represents a critical practice point: avoid prescribing medications without clear evidence that may cause side effects or worsen tinnitus 1.

Critical Safety Considerations

Screen for severe anxiety or depression and intervene promptly - tinnitus patients with psychiatric comorbidities have increased suicide risk 1, 2. This is not optional counseling; this is urgent psychiatric evaluation when indicated.

For tinnitus relieved by neck pressure, this suggests vascular etiology requiring dedicated temporal bone CT and CTA of head and neck to identify treatable causes like arterial dissection (treated with anticoagulation/antiplatelet therapy) or sigmoid sinus abnormalities (treated with surgical repair or endovascular embolization) 2.

Treatment Hierarchy Based on Evidence Quality

The American Academy of Otolaryngology-Head and Neck Surgery guidelines establish this clear hierarchy 1:

• Tier 1 (Recommend): CBT, hearing aids for those with hearing loss, education/counseling
• Tier 2 (May offer): Sound therapy for symptomatic relief
• Tier 3 (Do not recommend): Medications, supplements

This framework eliminates the ambiguity often present in tinnitus management and provides a clear path forward for every patient presentation.