What medications can cause tinnitus (ringing in the ears)?

Medications That Cause Tinnitus (Ringing in the Ears)

Highest Risk Medications

NSAIDs (Non-Steroidal Anti-Inflammatory Drugs) are among the most common culprits for medication-induced tinnitus, with frequent use significantly increasing risk. 1, 2

NSAIDs and Aspirin

• Tinnitus from NSAIDs is reversible and may signal high medication blood levels 1
• Frequent NSAID use (4-5 days/week) increases tinnitus risk by 17%, and daily use (6-7 days/week) increases risk by 7% 2
• High-dose aspirin commonly precipitates tinnitus, though low-dose aspirin (for cardiac protection) does not significantly elevate risk 2
• Moderate-dose aspirin used 6-7 days/week increases tinnitus risk by 16% in women under age 60 2
• Indomethacin is particularly associated with central nervous system effects including tinnitus, especially in older adults 1

Chemotherapy Agents

• Platinum-based chemotherapy (cisplatin, carboplatin) causes the highest risk of permanent tinnitus among all medications 3, 4
• Cisplatin causes permanent ototoxicity in 20-75% of patients and increases tinnitus risk 5.53-fold 3, 4
• Carboplatin increases tinnitus risk 3.75-fold 4
• No treatment can reverse established ototoxicity from cisplatin, making prevention and early detection critical 3

Aminoglycoside Antibiotics

• Streptomycin, kanamycin, amikacin, and other aminoglycosides cause irreversible ototoxicity affecting the eighth cranial nerve 1, 5
• Symptoms include tinnitus, vertigo, ataxia, nystagmus, and hearing loss 1
• Ototoxic antibiotics increase tinnitus risk 2.81-fold 4
• Risk increases when combined with other ototoxic drugs (amphotericin B, cephalosporins, ethacrynic acid, furosemide, vancomycin, cisplatin) 1

Macrolide Antibiotics

• Azithromycin can cause hearing loss, deafness, and tinnitus 1
• These effects are listed among general adverse effects including anaphylaxis and taste/smell perversion 1

Other Analgesics

• Acetaminophen used 6-7 days/week increases tinnitus risk by 18% 2
• The risk magnitude increases with frequency of use 2

Moderate Risk Medications

Antimalarial/Antirheumatic Drugs

• Chloroquine can cause tinnitus as an adverse effect 1

Tuberculosis Medications

• Streptomycin causes dose-dependent ototoxicity with tinnitus as an early warning sign 1
• Dosage should be reduced immediately if headache, vomiting, vertigo, or tinnitus occur 1
• Cycloserine causes central nervous system effects including vertigo, with risk highest at doses >500 mg/day 1

Cardiovascular Medications

• ACE inhibitors can cause drug-induced rhinitis but are not prominently associated with tinnitus 1
• Phosphodiesterase-5 inhibitors (erectile dysfunction medications) may cause drug-induced symptoms 1

Anticonvulsants (Paradoxically Used for Treatment)

• While some anticonvulsants are used to treat tinnitus, they can also cause it in certain contexts 6

Critical Clinical Evaluation

When tinnitus develops during medication use, immediately obtain comprehensive audiometric testing covering 500-8000 Hz to detect accompanying hearing loss 3

Essential Workup

• Pure tone audiometry is mandatory, as hearing loss frequently accompanies medication-induced tinnitus 3
• Delaying audiometric testing can lead to permanent damage 3
• Comprehensive otologic examination by the American Academy of Otolaryngology-Head and Neck Surgery standards 3

Warning Signs Requiring Urgent Evaluation

• Severe anxiety or depression related to tinnitus 3
• Progressive hearing loss 3
• Unilateral symptoms (may indicate other pathology) 7

Management Algorithm

Step 1: Identify and Discontinue Offending Agent

• Stop the causative medication immediately if medically feasible 1, 3
• For NSAIDs: tinnitus is typically reversible upon discontinuation 1
• For chemotherapy: tinnitus may be permanent even after stopping 3, 4

Step 2: Audiometric Assessment

• Obtain baseline audiometry before starting known ototoxic medications when possible 3
• Repeat testing if tinnitus develops 3

Step 3: Implement Evidence-Based Treatments

• Cognitive behavioral therapy (CBT) provides the strongest evidence for improving quality of life in persistent tinnitus (moderate to high strength of evidence) 3, 7
• Hearing aids are recommended for any degree of documented hearing loss (moderate strength of evidence) 3, 7
• Wide-band sound therapy combined with CBT-based counseling shows the strongest evidence base 7

Step 4: Special Considerations

• For chemotherapy patients: hearing aids and CBT remain beneficial even though ototoxicity cannot be reversed 3
• Ensure autoinjectable epinephrine availability if patient has alpha-gal syndrome (relevant for certain biologics) 8

Common Pitfalls to Avoid

• Never dismiss tinnitus as a minor side effect—it may signal dangerous medication levels or permanent damage 1, 3
• Do not continue ototoxic antibiotics without monitoring when tinnitus develops 1
• Avoid combining multiple ototoxic medications (aminoglycosides + loop diuretics + NSAIDs) 1
• Do not delay audiometric testing, as this can miss the window for preventing permanent damage 3
• Baseline tinnitus rates are high (47%) in older populations, so distinguish new-onset from pre-existing tinnitus 4

Medications With Lower/No Association

• Low-dose aspirin (81 mg daily for cardiac protection) does not significantly elevate tinnitus risk 2
• Trimethoprim-sulfamethoxazole lists tinnitus as a neurologic adverse effect but is not a primary cause 1
• Most medications without direct ototoxic properties do not cause tinnitus 5