What is the first‑line pharmacologic treatment for an adult with subjective tinnitus without a reversible cause?

First-Line Pharmacologic Treatment for Subjective Tinnitus

There is no first-line pharmacologic treatment for subjective tinnitus without a reversible cause—the American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends against routinely prescribing antidepressants, anticonvulsants, anxiolytics, or intratympanic medications due to insufficient evidence of benefit and potential for adverse effects. 1

Why Medications Are Not Recommended

• The strongest guideline evidence actively advises against pharmacologic therapy for persistent, bothersome tinnitus because randomized controlled trials have failed to demonstrate consistent benefit, while side effects and potential worsening of tinnitus remain significant concerns. 1

• Dietary supplements—including Ginkgo biloba, melatonin, and zinc—should also not be recommended due to lack of consistent evidence supporting their efficacy in tinnitus management. 1

• The historical use of various medications (vasodilators, lignocaine, glycerin) has not translated into evidence-based practice, and their efficacy remains questionable or extremely transient. 2

What Should Be Done Instead

Cognitive Behavioral Therapy (CBT) represents the only intervention with strong evidence from large randomized controlled trials showing definitive improvement in quality of life for patients with persistent, bothersome tinnitus. 1, 3

Evidence-Based Non-Pharmacologic Algorithm

1. Hearing aid evaluation and fitting should be the first intervention for any patient with documented hearing loss (even mild or unilateral), as hearing aids provide significant tinnitus relief with strong supporting evidence. 1

2. Education and counseling about tinnitus mechanisms, natural history, and management strategies must be provided to all patients with persistent tinnitus at the initial visit. 1

3. CBT referral is recommended for patients with persistent, bothersome tinnitus who do not achieve adequate relief from hearing aids and education alone. 1

4. Sound therapy may be offered as an adjunctive management option for symptomatic relief in persistent tinnitus. 1

Critical Screening Before Any Treatment

• Screen all tinnitus patients for severe anxiety or depression using validated instruments, because these conditions carry documented increased suicide risk and require immediate psychiatric intervention—not tinnitus-specific medication. 1

• Perform otoscopic examination to exclude reversible causes (cerumen impaction, middle ear effusion) before concluding the tinnitus has no reversible cause. 1

Common Pitfalls to Avoid

• Prescribing medications "to try something" represents poor practice when guidelines explicitly recommend against this approach due to lack of efficacy and potential harm. 1

• Missing concurrent psychiatric illness that requires treatment in its own right (not as tinnitus therapy) can lead to tragic outcomes given the elevated suicide risk. 1

• Overlooking mild hearing loss that could benefit from amplification—patients often don't report hearing difficulties even when audiometry documents loss that would respond to hearing aids. 1

When Medications May Have a Role

• For secondary tinnitus from Menière's disease, pharmacologic management targets the underlying vestibular disorder (diuretics for endolymphatic hydrops) rather than tinnitus specifically. 4, 2

• For tinnitus with comorbid depression or anxiety, psychiatric medications treat the mental health condition itself—not the tinnitus—though this may indirectly improve tinnitus tolerance. 1

• No causative pharmacologic treatment exists for established ototoxicity from platinum-based chemotherapy, though hearing aids and CBT remain beneficial. 1