What is the best treatment approach for an adult patient with tinnitus and no underlying medical conditions?

Best Treatment for Tinnitus

Cognitive behavioral therapy (CBT) is the single best treatment for tinnitus, as it has the strongest evidence for improving quality of life and reducing tinnitus-related distress in patients with persistent, bothersome symptoms. 1, 2

Treatment Algorithm for Adults with Tinnitus

Step 1: Assess for Hearing Loss

• Obtain comprehensive audiologic testing for any patient with tinnitus that is unilateral, persistent (≥6 months), or associated with hearing difficulties. 2
• If hearing loss is present—even if mild or unilateral—strongly recommend hearing aids as first-line intervention, as this addresses both hearing difficulties and tinnitus simultaneously. 1, 2

Step 2: Implement CBT as Primary Treatment

• Refer all patients with persistent, bothersome tinnitus to CBT, as this is the only treatment proven in large randomized controlled trials to definitively improve quality of life. 1, 2, 3
• CBT works by reducing tinnitus-related distress and promoting habituation rather than eliminating the sound itself. 1
• Approximately 80% of patients adapt to tinnitus over time, with the goal being habituation rather than complete silence. 1

Step 3: Add Sound Therapy as Adjunctive Treatment

• Recommend sound therapy to provide symptomatic relief through three mechanisms: stress relief, passive attention diversion, and active attention diversion. 1
• Sound therapy can be used alongside CBT but should not replace it as the primary intervention. 1

Step 4: Provide Education and Counseling

• All patients with persistent tinnitus require education about management strategies and realistic expectations. 2
• Emphasize that the goal is habituation and reduced distress, not complete elimination of the phantom sound. 1

Critical Treatments to AVOID

Medications Without Evidence

• Do not routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary tinnitus treatment due to insufficient evidence and potential significant side effects. 1, 2
• These medications may be appropriate only for treating comorbid psychiatric conditions, not tinnitus itself. 1

Dietary Supplements

• Do not recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements, as randomized controlled trials and systematic reviews show no consistent benefit. 1, 2
• These represent expensive, unproven treatments that provide false hope while incurring significant costs. 1

Red Flags Requiring Immediate Specialist Referral

Pulsatile Tinnitus

• Any pulsatile tinnitus (synchronous with heartbeat) requires thorough vascular evaluation with imaging (CTA or MRA) to identify potentially treatable vascular abnormalities. 1, 2
• Pulsatile tinnitus almost always requires imaging evaluation, unlike bilateral non-pulsatile tinnitus. 2

Unilateral Tinnitus

• Unilateral tinnitus warrants comprehensive audiologic examination and potentially imaging studies to rule out vestibular schwannoma or other structural lesions. 1, 2

Psychiatric Comorbidities

• Patients with tinnitus accompanied by severe anxiety or depression require prompt identification and intervention due to documented increased suicide risk in this population. 1, 2, 4
• Do not overlook psychiatric comorbidities, as these require professional intervention beyond tinnitus management. 1

Common Clinical Pitfalls to Avoid

Overlooking Mild Hearing Loss

• Do not dismiss mild or unilateral hearing loss—these patients still warrant hearing aid evaluation, as even minimal hearing loss can benefit from amplification. 1, 2

Pursuing Unproven Expensive Treatments

• Avoid recommending treatments like transcranial magnetic stimulation (TMS) or dietary supplements that lack robust evidence and may provide false hope while incurring significant costs. 1
• While one case report showed potential benefit combining rTMS with CBT 5, this lacks the large-scale randomized controlled trial evidence required for routine recommendation.

Setting Unrealistic Expectations

• Never promise complete elimination of tinnitus—set realistic expectations that approximately 80% of patients adapt over time without medical intervention, and the goal is habituation rather than silence. 1

Unnecessary Imaging

• Do not obtain imaging studies for bilateral, non-pulsatile tinnitus without focal neurological abnormalities or asymmetric hearing loss. 2

Special Considerations

Ménière's Disease

• If tinnitus occurs as part of Ménière's disease (with episodic vertigo lasting 20 minutes to 12 hours and fluctuating low-to-mid frequency hearing loss), manage the underlying vestibular disorder rather than treating tinnitus specifically. 6, 2

Medication-Induced Tinnitus

• For patients with chemotherapy-induced tinnitus (particularly platinum-based agents), no causative treatment exists for established ototoxicity, but hearing aids and CBT remain beneficial for symptom management. 2