What are the proven treatments for a patient suffering from tinnitus?

Proven Treatments for Tinnitus

Cognitive Behavioral Therapy (CBT) is the only treatment with strong evidence from randomized controlled trials demonstrating improved quality of life in patients with persistent, bothersome tinnitus and should be recommended as first-line therapy. 1, 2, 3

Treatment Algorithm for Persistent Tinnitus (≥6 months)

Step 1: Audiologic Assessment and Hearing Aid Evaluation

• All patients with tinnitus and any degree of hearing loss—even mild or unilateral—should receive a hearing aid evaluation immediately. 1, 2, 3
• Hearing aids provide significant relief by addressing the auditory deprivation that often underlies tinnitus, and this intervention has a preponderance of benefit over harm even in marginal hearing aid candidates. 1
• The level of hearing loss does not need to be severe; mild unilateral sensorineural hearing loss associated with tinnitus may benefit from amplification. 1

Step 2: Education and Counseling (Universal)

• Provide education and counseling about tinnitus management strategies to all patients with persistent, bothersome tinnitus. 1, 2, 3
• This foundational intervention helps patients understand the natural history of tinnitus and sets realistic expectations for management. 1

Step 3: Cognitive Behavioral Therapy

• Recommend CBT for all patients with persistent, bothersome tinnitus based on Grade B evidence from RCTs showing preponderance of benefit. 1, 2, 3
• CBT is the only intervention with definitive improvement effects demonstrated in large randomized controlled trials. 4, 5
• This therapy addresses the psychological distress, anxiety, depression, and sleep disturbances that accompany tinnitus. 4

Step 4: Sound Therapy (Optional Adjunct)

• Sound therapy may be recommended as an adjunctive management option for symptomatic relief, though evidence is less robust than for CBT. 1, 2
• Sound therapy works through three mechanisms: providing soothing sound for stress relief, using background sound to reduce contrast with tinnitus, and actively diverting attention with interesting sounds. 6
• Sound therapy combined with education and counseling is generally helpful, though insufficient evidence exists to support routine use of individual sound therapy options alone. 7

Treatments to Explicitly AVOID

Medications (Strong Recommendation Against)

• Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics (including benzodiazepines), or intratympanic medications for primary treatment of persistent, bothersome tinnitus. 1, 2, 3, 8
• This recommendation is based on systematic reviews and RCTs showing low strength of evidence, methodological concerns, and significant potential side effects without proven benefit. 1
• The quality improvement opportunity here is to decrease use of medications that may have no benefit but carry substantial adverse effect profiles. 1

Dietary Supplements (Strong Recommendation Against)

• Do NOT recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements for tinnitus management due to lack of consistent evidence of efficacy. 2, 3, 8

Other Interventions Not Recommended

• Transcranial Magnetic Stimulation (TMS) should not be recommended for routine tinnitus treatment. 3
• Insufficient evidence exists to recommend for or against acupuncture. 3

Special Clinical Scenarios

Unilateral or Pulsatile Tinnitus (Red Flags)

• Obtain imaging studies (MRI with contrast preferred, or CTA/MRA for pulsatile tinnitus) to rule out vestibular schwannoma, vascular abnormalities, or other structural pathology. 2, 8
• Unilateral tinnitus mandates imaging due to 10-15% risk of identifiable underlying causes. 8
• If imaging reveals structural pathology, refer to neurotology/neurosurgery for definitive management. 8

Psychiatric Comorbidities

• Screen all patients with bothersome tinnitus for anxiety and depression, as psychiatric comorbidities increase suicide risk and require prompt intervention. 2, 8
• While antidepressants should not be used for primary tinnitus treatment, they may be appropriate for treating comorbid mood disorders. 5

Chemotherapy-Induced Tinnitus

• No causative treatment exists for established platinum-based chemotherapy ototoxicity. 2
• Hearing aids remain beneficial for chemotherapy-induced tinnitus with associated hearing loss. 2
• CBT strategies can be offered with moderate supporting evidence. 2

Common Pitfalls to Avoid

• Do not overlook mild hearing loss that could benefit from hearing aid intervention—even minimal hearing loss warrants evaluation. 2, 8
• Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus. 2, 3
• Do not obtain imaging studies routinely unless tinnitus is unilateral, pulsatile, associated with focal neurological abnormalities, or accompanied by asymmetric hearing loss. 2, 5
• Do not defer treatment indefinitely—while some patients habituate naturally, those with persistent symptoms (≥6 months) are unlikely to resolve spontaneously and benefit from active intervention. 1

Evidence Quality Considerations

The strength of recommendations varies: CBT has Grade B evidence from RCTs; hearing aids have Grade C evidence from observational studies but high confidence due to consistent benefit and low harm; medications have Grade B evidence against their use based on RCTs with methodological concerns showing lack of efficacy. 1 The convergence of multiple guidelines from the American Academy of Otolaryngology-Head and Neck Surgery provides robust support for this treatment algorithm. 1, 2, 3, 8