What is the best treatment approach for an adult patient with tinnitus?

Best Treatment for Tinnitus

Cognitive behavioral therapy (CBT) is the single most effective treatment for persistent, bothersome tinnitus, with the strongest evidence for improving quality of life and reducing tinnitus-related distress. 1, 2

Initial Assessment and Risk Stratification

Before initiating treatment, determine if the tinnitus requires urgent evaluation by checking for these red flags:

• Pulsatile tinnitus → requires vascular imaging (CTA or MRA) to rule out vascular abnormalities 1, 2
• Unilateral tinnitus → obtain comprehensive audiologic examination and consider imaging to exclude vestibular schwannoma 1, 2
• Severe anxiety or depression → immediate psychiatric intervention due to increased suicide risk in tinnitus patients 1, 2, 3
• Asymmetric hearing loss or focal neurologic findings → imaging studies indicated 2

For bilateral, non-pulsatile tinnitus without these features, imaging is not necessary. 2

Evidence-Based Treatment Algorithm

Step 1: Audiologic Evaluation

Obtain comprehensive audiometry for all patients with persistent tinnitus (≥6 months), unilateral tinnitus, or any hearing difficulties. 2 This should include pure tone audiometry covering 500-8000 Hz. 3

Step 2: Hearing Aid Evaluation (If Hearing Loss Present)

Recommend hearing aids for ANY degree of hearing loss—even mild or unilateral. 1, 2 This intervention addresses both hearing difficulties and tinnitus simultaneously and has moderate-to-high quality evidence. 1, 4 Do not overlook mild hearing loss, as this is a common pitfall. 1

Step 3: Cognitive Behavioral Therapy

Refer for tinnitus-specific CBT as the cornerstone intervention. 1, 2 CBT has the strongest evidence base for improving quality of life in tinnitus patients, though availability may be limited in some regions. 4, 5 The goal is habituation and reduced distress rather than complete elimination of tinnitus. 1

Step 4: Sound Therapy (Adjunctive)

Consider sound therapy as a supplementary management option to provide symptomatic relief through stress reduction and attention diversion. 1, 2 Evidence is less robust than for CBT, but it can be combined with counseling. 4

Step 5: Education and Counseling

Provide education about tinnitus mechanisms and natural history for all patients with persistent, bothersome tinnitus. 2 Approximately 80% of patients adapt over time without medical intervention. 1

Treatments to Explicitly AVOID

The following interventions lack evidence and should NOT be recommended:

• Antidepressants, anticonvulsants, anxiolytics, or intratympanic medications → insufficient evidence and potential significant side effects 1, 2
• Dietary supplements (Ginkgo biloba, melatonin, zinc) → RCTs show no consistent benefit 1, 2
• Transcranial magnetic stimulation → expensive and lacks evidence 1

Exception: Antidepressants may be appropriate specifically for treating comorbid depression (not the tinnitus itself), and melatonin may help with sleep disturbance. 6

Special Populations

Medication-Induced Tinnitus (e.g., Cisplatin)

• No treatment can reverse established ototoxicity from platinum-based chemotherapy 2, 3
• Hearing aids and CBT remain beneficial for managing symptoms 2, 3
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but adult use is uncertain 2

Ménière's Disease-Associated Tinnitus

For tinnitus occurring as part of Ménière's disease, treatment focuses on controlling the underlying vestibular disorder rather than tinnitus specifically. 7 The tinnitus typically fluctuates with disease activity.

Critical Pitfalls to Avoid

• Do not pursue expensive unproven treatments that provide false hope while incurring significant costs 1
• Do not expect complete tinnitus elimination—set realistic expectations for habituation rather than silence 1
• Do not ignore psychiatric comorbidities—screen for anxiety and depression given suicide risk 1, 2
• Do not delay audiometric testing in medication-induced tinnitus, as hearing loss frequently accompanies it 3
• Do not prescribe medications without clear evidence that may cause side effects or worsen tinnitus 2

Summary Treatment Hierarchy

1. Hearing aids (if any hearing loss present) 1, 2
2. Cognitive behavioral therapy (strongest evidence for quality of life) 1, 2, 5
3. Sound therapy (adjunctive, weaker evidence) 1, 2
4. Education and counseling (all patients) 2

This approach prioritizes interventions with proven benefit while avoiding ineffective treatments that waste resources and potentially cause harm.