Second-Line Pharmacological Management of Tinnitus
There are no recommended second-line pharmacological treatments for chronic subjective tinnitus because the American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against routinely prescribing antidepressants, anticonvulsants, anxiolytics, or intratympanic medications for primary treatment of persistent, bothersome tinnitus due to insufficient evidence of efficacy and significant potential for side effects. 1, 2, 3
Why Pharmacotherapy Is Not Recommended
The evidence base consistently demonstrates that medications lack proven benefit for tinnitus management:
Antidepressants, anticonvulsants, and anxiolytics should not be prescribed as routine tinnitus treatments because systematic reviews and randomized controlled trials show insufficient efficacy, notable adverse effects, and possible worsening of tinnitus symptoms (Grade B evidence showing harm may outweigh benefit). 2, 3
Intratympanic medications are similarly not recommended for persistent, bothersome tinnitus due to low strength of evidence and lack of demonstrated benefit. 1, 2
Dietary supplements including Ginkgo biloba, melatonin, and zinc should not be advised because the literature fails to demonstrate consistent therapeutic benefit across multiple trials. 1, 2, 3
What Should Be Done Instead After First-Line Therapy Fails
If optimal non-pharmacologic therapy (CBT, hearing aids, education/counseling) has been tried without adequate improvement, the appropriate next steps are not pharmacological but rather:
Reassessment and Alternative Non-Pharmacologic Options
Sound therapy using wide-band sound generators, environmental sound enrichment, or combination devices may provide additional symptomatic relief as an adjunctive approach, though evidence is less robust than for CBT. 2
Patients whose symptoms persist should be reassessed to exclude alternative diagnoses such as Ménière's disease, otosclerosis, or delayed-presentation acoustic neuroma, as 10-15% of bilateral tinnitus cases have identifiable underlying causes that emerge only after extended observation. 1
Addressing Psychiatric Comorbidities (Not Primary Tinnitus)
If severe anxiety or depression is present, psychiatric intervention should be initiated immediately due to documented increased suicide risk in tinnitus patients with psychiatric comorbidities—but this treats the comorbidity, not the tinnitus itself. 1, 2
Medications prescribed in this context target the psychiatric diagnosis (depression, anxiety disorder) rather than serving as tinnitus-specific therapy. 1
Multidisciplinary Team Approach
Long-term follow-up with otolaryngology, audiology, and mental health professionals is necessary because some patients will have underlying causes identified only after extended observation, and continued audiologic and psychological support is required for those with partial or no improvement. 1
Audiology should optimize hearing-assistive technology and ensure proper fitting of amplification devices, as even mild hearing loss warrants evaluation and intervention. 1, 2
Critical Pitfalls to Avoid
Do not prescribe medications without clear evidence of benefit that may cause side effects or worsen tinnitus—this is the most common error in tinnitus management. 1, 2
Do not overlook psychiatric screening, as neglecting to assess for severe anxiety or depression can miss heightened suicide risk. 1, 2
Do not defer treatment indefinitely; patients with persistent symptoms are unlikely to resolve spontaneously and benefit from active non-pharmacologic intervention rather than watchful waiting. 2
The Bottom Line
Second-line management for chronic subjective tinnitus after failed optimal non-pharmacologic therapy involves intensifying or optimizing non-pharmacologic approaches (sound therapy, reassessment for missed diagnoses, psychiatric treatment of comorbidities) rather than introducing pharmacological agents, which lack evidence of efficacy and carry risk of harm. 1, 2, 3