What are the recommended first‑line and second‑line management options for a patient with tinnitus?

Tinnitus Treatment

For patients with persistent, bothersome tinnitus, cognitive behavioral therapy (CBT) should be recommended as first-line treatment, as it is the only intervention with strong randomized controlled trial evidence demonstrating improved quality of life. 1, 2

First-Line Management

Cognitive Behavioral Therapy (CBT)

• CBT is the strongest evidence-based treatment and should be recommended to all patients with persistent, bothersome tinnitus. 1, 2
• This is based on Grade B evidence from randomized controlled trials showing preponderance of benefit over harm. 1
• CBT specifically targets the psychological distress and maladaptive coping patterns that perpetuate tinnitus-related disability. 3

Education and Counseling

• All patients with persistent tinnitus must receive education about management strategies and the natural history of the condition. 1, 2
• This foundational intervention helps set realistic expectations and reduces anxiety about the symptom. 2
• Education should emphasize that tinnitus is typically benign and that most patients habituate over time. 1

Hearing Aid Evaluation

• For any patient with tinnitus and hearing loss of any degree—even mild or unilateral—a hearing aid evaluation should be recommended immediately. 1, 2
• Hearing aids provide significant relief by addressing auditory deprivation that often underlies tinnitus. 2
• The level of hearing loss does not need to be severe; even marginal hearing aid candidates with tinnitus may benefit. 1

Second-Line Management

Sound Therapy

• Sound therapy may be recommended for symptomatic relief in patients with persistent tinnitus. 1, 4
• This includes wide-band sound generators, environmental sound enrichment, or combination devices. 5
• Evidence is less robust than for CBT but shows potential benefit with minimal harm. 1

Treatments to AVOID

Medications

• Do NOT routinely prescribe antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of tinnitus. 1, 2
• These medications lack sufficient evidence of efficacy, carry significant side effects, and some (particularly antidepressants) may actually worsen tinnitus. 1, 2
• This recommendation is based on Grade B evidence from systematic reviews and RCTs with methodological concerns. 1
• The only exception: treat coexisting psychiatric conditions (depression, anxiety) independently if present, but not as primary tinnitus therapy. 4

Dietary Supplements

• Do NOT recommend Ginkgo biloba, melatonin, zinc, or other dietary supplements. 1, 2
• These lack consistent evidence of efficacy despite widespread availability and patient interest. 1, 2

Acupuncture

• No recommendation can be made regarding acupuncture due to poor quality trials and no established benefit. 1

Critical Initial Evaluation Steps

Red Flags Requiring Imaging

• Obtain imaging (MRI or CTA/MRA) if tinnitus is unilateral, pulsatile, associated with focal neurologic abnormalities, or accompanied by asymmetric hearing loss. 4, 2
• Pulsatile tinnitus almost always requires imaging to rule out vascular abnormalities or tumors. 4
• Unilateral tinnitus requires evaluation for vestibular schwannoma. 2

Psychiatric Screening

• Screen all patients with bothersome tinnitus for anxiety and depression, as psychiatric comorbidities increase suicide risk and require prompt intervention. 1, 4, 2
• Patients with severe anxiety or depression require immediate mental health referral. 1

Treatment Algorithm

1. Perform targeted history and physical examination to identify potentially treatable underlying conditions (cerumen impaction, otosclerosis, Menière's disease). 1, 4

2. Determine if imaging is needed based on presence of unilateral, pulsatile, or neurologically concerning features. 4, 2

3. Obtain comprehensive audiologic examination for all patients with unilateral tinnitus, persistent tinnitus (≥6 months), or hearing difficulties. 4

4. If hearing loss is present at any degree: Recommend hearing aid evaluation immediately. 1, 2

5. For all patients with persistent, bothersome tinnitus: Provide education/counseling AND recommend CBT. 1, 2

6. Consider sound therapy as adjunctive treatment for additional symptomatic relief. 1, 4

7. Screen for and treat psychiatric comorbidities independently if present. 4, 2

Common Pitfalls to Avoid

• Do not overlook mild hearing loss—even minimal hearing impairment warrants hearing aid evaluation in tinnitus patients. 1, 2
• Do not prescribe medications without clear evidence—this exposes patients to side effects without proven benefit and may worsen tinnitus. 1, 2
• Do not defer treatment indefinitely—patients with persistent symptoms are unlikely to resolve spontaneously and benefit from active intervention. 2
• Do not fail to image pulsatile or unilateral tinnitus—these presentations require exclusion of serious underlying pathology. 4, 2

Special Populations

Drug-Induced Tinnitus

• For chemotherapy-induced tinnitus (cisplatin, carboplatin), no treatment can reverse established ototoxicity, but hearing aids and CBT remain beneficial for symptom management. 4, 6
• Multiple medications can induce tinnitus, including aminoglycosides, thiazide diuretics, cardiovascular agents, and psychiatric medications. 6
• Consider discontinuation of reversible ototoxic agents when possible. 6