What are the effective treatments for tinnitus?

Effective Treatments for Tinnitus

Evidence-Based First-Line Treatments

Cognitive Behavioral Therapy (CBT) is the single most effective treatment for improving quality of life in patients with persistent, bothersome tinnitus and should be your primary therapeutic recommendation. 1, 2, 3

Core Treatment Algorithm

For patients with any degree of hearing loss (even mild or unilateral):

• Recommend hearing aid evaluation immediately, as hearing aids provide significant symptomatic relief and address the underlying auditory deprivation that perpetuates tinnitus 1, 4
• This applies even when hearing loss seems minimal on audiometry 1

For all patients with persistent, bothersome tinnitus:

• Provide education and counseling about tinnitus mechanisms and management strategies as an essential foundation 1
• Refer for CBT, which has the strongest evidence from randomized controlled trials for improving quality of life 1, 5, 3
• Consider sound therapy as an adjunctive option for symptomatic relief, though evidence is less robust than for CBT 1, 4

Critical Safety Screening

Screen every tinnitus patient for severe anxiety or depression, as these require immediate psychiatric intervention due to documented suicide risk in this population. 6, 1, 7

Treatments That Should NOT Be Recommended

Do not prescribe the following due to insufficient evidence and potential harm:

• Antidepressants, anticonvulsants, or anxiolytics for primary tinnitus treatment (may be appropriate for comorbid psychiatric conditions, but not for tinnitus itself) 1
• Intratympanic medications lack evidence for persistent tinnitus 1
• Dietary supplements including Ginkgo biloba, melatonin, or zinc—these consistently fail to show benefit in clinical trials 1, 2
• Pharmacological treatments have no proven efficacy specifically for chronic tinnitus 2

Initial Evaluation Requirements

Before initiating treatment, perform targeted assessment to identify treatable underlying conditions:

• Otoscopic examination to exclude cerumen impaction, middle ear effusion, or retrotympanic masses 6, 8
• Determine if tinnitus is pulsatile versus non-pulsatile, unilateral versus bilateral 1, 8
• Obtain comprehensive audiologic examination for unilateral tinnitus, persistent tinnitus (≥6 months), or associated hearing difficulties 1

Imaging Indications (Critical Decision Points)

Order imaging ONLY when:

• Tinnitus is pulsatile (requires CTA or MRA to evaluate vascular abnormalities) 1, 8
• Tinnitus is unilateral or asymmetric (requires MRI with contrast to exclude vestibular schwannoma) 1, 8
• Focal neurologic abnormalities are present 1
• Asymmetric hearing loss is documented 1

Do NOT order imaging for bilateral, non-pulsatile tinnitus without neurologic deficits—this is a strong recommendation to avoid unnecessary testing. 1, 8

Long-Term Management Structure

Establish multidisciplinary care involving:

• Otolaryngology for ongoing medical oversight and monitoring for delayed-presentation causes (identified in 10-15% of cases only after extended follow-up) 1
• Audiology for hearing aid fitting, sound therapy devices, and hearing-assistive technology 1
• Mental health professionals for CBT delivery and management of psychiatric comorbidities 1

Regular follow-up is mandatory because underlying etiologies may become apparent only after extended observation, and most patients require continued support for partial or incomplete improvement. 1

Common Pitfalls to Avoid

• Overlooking mild hearing loss that could benefit from amplification—even unilateral or mild loss warrants hearing aid evaluation 1, 8
• Prescribing medications without evidence that may worsen tinnitus or cause side effects 1, 8
• Failing to screen for psychiatric comorbidities that increase suicide risk 6, 1, 7
• Ordering brain imaging for typical bilateral tinnitus without red flags—this wastes resources and delays appropriate treatment 1, 8
• Recommending unproven supplements that lack efficacy and may give false hope 1

Special Populations

For chemotherapy-induced tinnitus (platinum-based agents):

• No treatment can reverse established ototoxicity 1
• Hearing aids and CBT remain beneficial for symptom management 1
• Sodium thiosulfate may prevent ototoxicity in children receiving cisplatin, but adult use is uncertain 1

For tinnitus associated with Ménière's disease:

• Manage the underlying vestibular disorder rather than treating tinnitus specifically 1