Treatment Options for Tinnitus
Initial Classification and Risk Stratification
The first critical step is determining whether the tinnitus is pulsatile or non-pulsatile, as this fundamentally changes your diagnostic and therapeutic approach. 1
For Pulsatile Tinnitus:
- Imaging is mandatory because over 70% of cases have an identifiable vascular or structural cause, including life-threatening conditions like dural arteriovenous fistulas or arterial dissection 2
- Order CT angiography (CTA) of head and neck with contrast as first-line imaging when suspecting vascular causes 1, 2
- Alternatively, use high-resolution CT temporal bone (non-contrast) if you suspect paragangliomas, glomus tumors, or jugular bulb abnormalities 2
- Reserve MRI/MRA for cerebellopontine angle lesions or when CT/CTA are negative but suspicion remains high 2
For Non-Pulsatile Tinnitus:
- Do NOT order imaging unless the tinnitus is unilateral, associated with focal neurologic abnormalities, or accompanied by asymmetric hearing loss 1, 3
- Obtain comprehensive audiologic examination for any unilateral tinnitus or tinnitus persisting ≥6 months 1, 3
Evidence-Based Treatment Algorithm
Step 1: Identify and Treat Underlying Causes
- Perform otoscopic examination to identify vascular retrotympanic masses (paragangliomas) 4, 1
- Review all medications for ototoxic agents 4
- Check for cerumen impaction, middle ear disorders, or labyrinthine pathology 4
Step 2: Assess If Tinnitus Is Bothersome
- Use validated questionnaires (Tinnitus Handicap Inventory or Tinnitus Functional Index) to quantify impact 5
- Non-bothersome tinnitus requires only reassurance and education 1, 3
Step 3: For Persistent, Bothersome Tinnitus (≥6 months)
Cognitive Behavioral Therapy (CBT) is the ONLY treatment with strong evidence for improving quality of life and should be your primary recommendation. 1, 5, 6, 3
Additional Evidence-Based Options:
- Hearing aids for patients with any degree of hearing loss, even if mild or unilateral 1, 5, 3
- Sound therapy may provide symptomatic relief, though evidence is less robust than CBT 1, 3
- Education and counseling about tinnitus mechanisms and management strategies for all patients 1, 3
Treatments You Should NOT Recommend
The American Academy of Otolaryngology explicitly recommends AGAINST the following due to insufficient evidence and potential harm: 1, 5, 3
- Antidepressants, anticonvulsants, or anxiolytics (including benzodiazepines) for primary tinnitus treatment
- Intratympanic medications
- Dietary supplements: Ginkgo biloba, melatonin, zinc, or other supplements
- Transcranial magnetic stimulation
Critical Red Flags Requiring Urgent Action
Psychiatric Comorbidities:
- Screen all patients with bothersome tinnitus for severe anxiety or depression 4, 1
- Suicide risk is elevated in tinnitus patients with psychiatric comorbidities—these patients require prompt psychiatric referral 4, 5
Unilateral Tinnitus:
- Always obtain MRI with contrast to rule out vestibular schwannoma 5
- Approximately 10-15% will have identifiable pathology 5
Sudden Hearing Loss with Tinnitus:
- Initiate urgent corticosteroid therapy 5
Common Pitfalls to Avoid
- Never dismiss pulsatile tinnitus as benign—it requires imaging in nearly all cases 2
- Don't overlook mild hearing loss—even minimal hearing impairment benefits from hearing aid evaluation 1, 5
- Avoid prescribing medications without clear evidence—this exposes patients to side effects without proven benefit 1, 5
- Don't order imaging for bilateral, non-pulsatile, non-localizing tinnitus—this wastes resources and may lead to incidental findings requiring unnecessary follow-up 1, 3