Cyclobenzaprine Should Not Be Used for Tinnitus
Do not prescribe cyclobenzaprine for tinnitus, as the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routine use of medications including muscle relaxants for treating persistent, bothersome tinnitus. 1
Guideline-Based Recommendation
The 2014 AAO-HNS clinical practice guideline provides a clear directive against medical therapy for tinnitus:
Clinicians should not routinely recommend antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for a primary indication of treating persistent, bothersome tinnitus (Grade B recommendation based on RCTs and systematic reviews). 1
The guideline emphasizes avoiding unproven therapy, side effects/adverse events (including medications that can worsen tinnitus), false hope, and unnecessary expense. 1
The benefit-harm assessment shows a preponderance of benefit in avoiding these medications rather than using them. 1
Why the Research Evidence Doesn't Override Guidelines
While two open-label studies from 2012 suggested cyclobenzaprine might reduce tinnitus severity 2, 3, these findings have critical limitations:
Both studies were open-label (not blinded), which introduces significant bias in a condition where placebo effects are substantial. 2, 3
One study showed only 24% of patients had a clear response with 53% reduction in tinnitus intensity, meaning 76% did not respond meaningfully. 3
These studies have never been validated in placebo-controlled, double-blind trials despite being published over a decade ago. 2
A 2014 systematic review concluded that pharmacotherapy for tinnitus lacks support from high-quality randomized controlled trials. 4
What Should Be Recommended Instead
The AAO-HNS guideline provides evidence-based alternatives:
Cognitive-behavioral therapy (CBT) should be recommended for persistent, bothersome tinnitus (based on RCTs with preponderance of benefit). 1
Hearing aid evaluation should be recommended for patients with hearing loss and tinnitus (high confidence in evidence despite observational study basis). 1
Sound therapy may be recommended for persistent tinnitus. 1
Education and counseling about tinnitus management strategies have demonstrated value. 1
Common Pitfalls to Avoid
Do not be swayed by patient requests for medication based on internet research citing the 2012 open-label studies—explain that these have not been validated in rigorous trials. 2, 3
Avoid the temptation to "try something" when patients are desperate—cyclobenzaprine carries risks of sedation, anticholinergic effects, and falls (particularly in older adults), and can cause withdrawal symptoms requiring 2-3 week taper after prolonged use. 5, 6
Remember that some antidepressants can actually worsen tinnitus as a side effect, highlighting why unproven pharmacotherapy should be avoided. 1, 7