Timothy C. Hain, MD. •Page last modified: July 22, 2020
This document is not written for or intended for use in legal proceedings.
The algorithm that we use in our practice to diagnose and treat tinnitus is here (a PDF graphic). After a diagnostic step, there are many branch points involving treatment trials.
The bottom line is that it is unusual (although not impossible) for people to get substantial relief from medication, devices, diet, or surgery. In fact, "obsessing" about tinnitus, generally tends to make it more persistent and worse. Thus paradoxically enough, doctors tend to discourage reading of web pages like this one, or joining of support groups. Most people "get used" to tinnitus, and learn to "tune it out". When this doesn't happen, the treatments that work the best for tinnitus are those that alter ones emotional state -- antidepressants and antianxiety drugs, and ones that allow you to get a full night's sleep.
Pan et al (2015) reported in a survey of 258 patients with tinnitus, that 38% reported that noise made tinnitus better, and 15% that relaxation made it better. Things that made it worse included being in a quiet place (48%), stress (36%), being in a noisy place (32%), and lack of sleep (27%). Only a few patients reported that coffee/tea or foods made their tinnitus worse.
The bad news in more detail : Dobie (1999) reviewed the 69 randomized controlled trials of tinnitus treatments. According to Dr. Dobie, no treatment can yet be considered "well established" in terms of providing replicable long-term reduction of tinnitus impact, in excess of placebo effects. Support and counseling are probably helpful as are tricyclic antidepressants in severe cases. Benzodiazepines, newer antidepressants and electrical stimulation deserve further study. More recently, Hoare et al (2011) reviewed 28 randomized controlled trials. They concluded "The efficacy of most interventions for tinnitus benefit remains to be demonstrated conclusively. In particular, high-level assessment of the benefit derived from those interventions most commonly used in practice, namely hearing aids, maskers, and tinnitus retraining therapy needs to be performed." Antidepressants were the only drug class to show any evidence of potential benefit.
But don't lose all hope: Dobie made the point that tinnitus is likely multifactorial, and the usual study design is likely not well chosen for this situation. A study design where initially an open-label study is performed, followed by a randomized placebo controlled trial might find patient groups that respond to a medication. This seems very logical. Some hope is offered by the observation that cochlear implants often relieve tinnitus (in persons who are completely deaf).
If a specific cause for tinnitus is found, then your physician may be able to eliminate the noise. Examples of specific causes include medication, tumors, infections, Meniere's disease, TMJ and otosclerosis. Tinnitus due to the tensor tympani can be treated by transection of that muscle. To find a specific cause it may require a fairly extensive workup including X-rays and blood tests. However, even after extensive workup, most causes of tinnitus go undiagnosed.
If a specific cause of tinnitus is not found, it is unlikely that the tinnitus can be gotten rid of. At best, one might get partial relief from some of the strategies to be described in the next few paragraphs. However, even though treatment may not be available, tinnitus should be checked into, as tinnitus may be a warning sign of a serious disorder such as a tumor of the 8th nerve, or other disorder which may impair hearing. Tinnitus does tend to gradually get better, but many persons with severe tinnitus still experience distress 5 years later. Tolerance of tinnitus increases with time. (Andersson et al, 2001).
Medications may occasionally help lessen the noise even though no cause can be found. In general, we are not at all enthused about medication treatment as the side effects can be substantial and the results are often unimpressive. In randomized clinical trials, for the most part, the agents under study have failed to demonstrate elimination of tinnitus more frequently than have placebos (Dobie RA, 1999).
Medication to deal with the psychological fallout of tinnitus is often useful -- antidepressants and anti-anxiety medications can be very helpful. This is because of the very high correlation between anxiety and depression with tinnitus-related annoyance and severity (Pinto et al, 2014). We are not suggesting here that anxiety/depression causes tinnitus -- but rather that tinnitus is associated with some treatable psychiatrical disturbances.
Medications that are well accepted in treatment of Tinnitus
- Lorazepam or klonazepam (in low doses). These are "benzodiazepines", mainly used for anxiety (Gananca et al, 2002; Dobie, 2003)
- Amitriptyline or nortriptyline (again in low doses). These are "tricyclic antidepressants".
- SSRI medications (Bilici et al, 2013)
Comment. Benzodiazepines and tricyclics probably mainly change emotional responses to tinnitus. Any sort of relief, however, is important.
Robinson (2007) reviewed use of antidepressants for tinnitus. At that date there were 4 double-blind placebo controlled trials of antidepressants for tinnitus. Three out of four trials resulted in a favorable outcoume (Nortriptyline, Paroxetine, Sertraline). The fourth trial of Trimipramine reported an 8dB increase. Robinson reported that tinnitus in depressed patients appears more responsive to antidepressants than in non-depressed patients. Mechanisms for impovement were suggested to be direct effects of increased serotonin on auditory pathways, or indirect effects of tinnitus on depression or anxiety.
We have also had some patients get relief from other antidepressants including the SSRI family and SNRI family, and especially with low dose venlafaxine, which we find helps in reducing central sensory syndromes such as allodynia as is found in migraine headache.
The anticonvulsants such as mysoline may affect some patients who have tinnitus due to 8th nerve irritation. Mysoline (Primidone) contains phenobarbital, which is sedating. On the other hand, Hoekstrat et al (2011) suggested that in general these drugs do not work for tinnitus. This is not very surprising.
There is a small literature concerning use of intravenous and local anesthesia for tinnitus. See this link for more.
Botox for tinnitus:
Lainez and Piera (2007) reviewed a paper published concerning use of Botox for tinnitus. Stidham et al (2005) injected botox into the area of the ear(above, and 2 places behind), the arm, and compared with placebo. This study suggested that Botox might improve tinnitus to a small extent (7 improved with active, 2 improved with placebo). Lainez and Piera suggested that the mechanism was reduction of peripheral inputs from cervical, temporal, frontal and periauricular pathways.
Liu et al (2011) reported use of botox for tinnitus due to tensor tympani myoclonus, by inserting gelfoam with botox through a perforation in the tympanic membrane. This method appears to us to be overly invasive.
Atorvastatin (Lipitor). A recent trial in older people showed that atorvastatin had no effect on the rate of hearing deterioration but there was a trend toward improvement in tinnitus scores over several years. (Olzowy et al, 2007). A trial of simvistatin and ginkgo together was ineffective (Canis, Olzowy et al, 2009). There are some papers about diet and lipids. We think controlling hyperlipidemia is a good idea in general, as well as in tinnitus in particular.
Campral, is a medication FDA approved for treatment of abstinent alcoholics. A paper from south America reported that it is effective for tinnitus. This is an off-label use of this medication. At this writing (4/09), we think it is ineffective. Because it is easily available in the US, and has a rather benign side effect profile, we think that it is a good candidate for medication trials. We have had no success with it in a few patients.
Pramipexole was recently reported effective for tinnitus in a study of 40 patients with age related hearing loss in Hungary. (Sziklai and others, 2011). It seems very unlikely to us that a dopamine agonist should be useful in tinnitus. This work needs to be confirmed by others.
Trimetazidine. This is a drug designed for heart disease, that is marketed in Europe for vertigo and tinnitus. It's brand name is Vasterel. The author of this page has had no experience with this medication for Meniere's. Some authors indicate that it is a placebo. (anon, 2000)
Anticonvulsants. According to Hoeksra et al, there is no evidence that anticonvulsants have a "large positive effect" on tinnitus, but a small effect (of doubtful clinical significance) has been demonstrated. They reviewed studies of gabapentin, carbamazepine, lamotrigine and flunarizine. (We were not aware flunarizine was an "anticonvulsant", and it is not approved in the USA for any clinical use).
Shim et al (2011) reported that for acute subjective idiopathic tinnitus, the combination of alprazolam and intratympanic dexamethasone injections was significantly higher (75%) than treatment with alprazolam alone (50%). As it would be difficult to placebo control an intratympanic treatment, we think that this conclusion needs confirmation.
Hearing aids and other devices called "maskers" may also help alleviate tinnitus.
While Hearing aids are often recommended as treatment of tinnitus, according to Hoare(2014) from the Cochrane Database, the quality of evidence for their effect is so poor that no conclusion can be made. That being said, we think If you have tinnitus associated with a hearing loss, a hearing aid is a reasonable thing to try. Be sure that you try the hearing aid before buying one, as tinnitus is not always helped by an aid.
Nearly all states mandate a 1-month money-back guarantee built into hearing aid dispensing. This is because these devices are expensive, and don't always work.
It also seems possible that a hearing aid might exacerbate tinnitus, as many people develop "ringing" of their ears after exposure to loud noise.
Cochlear implants for tinnitus (see more about cochlear implants here).
Cochlear implants, which are used for severe bilateral unaidable hearing loss, usually improve tinnitus (Amoodi et al, 2011). They also work reasonably well for tinnitus associated with unilateral hearing loss (Arts et al, 2012).
There is an unfortunate interaction between Medicare insurance coverage and CI treatment for tinnitus in unilateral deafness patients. Medicare guidelines require that the hearing loss be bilateral. Thus someone who reaches the age of 65, and is automatically enrolled in Medicare, will generally not be able to get a CI through their commercial insurance for unilateral deafness and tinnitus. This is because commercial insurance usually becomes "secondary" when one goes on Medicare, meaning that things that were previously covered by commercial insurance, stop being covered once you have dual insurance (and are paying even more !). This unfortunate interaction is something to consider if you have unilateral deafness, severe tinnitus, and are approaching the age of 65.
Maskers (for more about masking, see here)
We are generally in favor of maskers (see below). We try masking in almost all patients in our clinic.
These are devices based on the idea that tinnitus is usually worst when things are very quiet. Listening to the interstation static on the FM radio, tapes of ocean surf, fans, and the like may be helpful. Pillow speakers sold by Radio Shack may be helpful in order to avoid disturbing others. There are numerous "apps" available on smartphones that implement masking. This is a very cheap method.
Tinnitus maskers are devices fitted and sold by audiologists. Controlled studies of maskers have shown small effects (Dobie, 1999). Given that smartphone apps do the same thing as tinnitus maskers, and that most newer hearing aids are blu-tooth capable, we see little reason to pay for a masker-hearing aid when one already owns a cell phone.
A discussion of the Neuromonic's masking device can be found by clicking on the link above. Briefly, we think that smartphone apps are a much more efficient method of doing much the same thing.
Tinnitus is often modulated by somatic input such as jaw movement. It would make sense that electrical stimulation might also modulate tinnitus. There is a small literature with some positive and negative data. This area seems to us worthy of more research.
TMS -- transcranial magnetic stimulation.
This is an investigational approach, which presently seems slightly promising. TMS involves brain stimulation using very high intensity magnetic pulses. It is somewhat similar to a "gentle" electroshock treatment, and clearly works on the brain rather than the inner ear. TMS seems to be somewhat helpful for depression and migraine, and one would think that a modality that worked for these, would also work to some extent for tinnitus. There is presently some evidence that it is helpful (Smith et al, 2007; Kleingjung et al, 2007; Mennemeier et al, 2008; Bilici et al, 2013) as well as studies suggesting it is no better than placebo (Piccirillo et al, 2011). This treatment is available only in persons who are in research environments, or those with refractory depression. We are cautiously optimistic about TMS, especially in individuals with depression.
Friedland and associates (2008) reported results of brain electrical stimulation in 8 patients. This was an uncontrolled study. The authors concluded that this technique "warrants further investigation". Two patients had persistent improvement of pure tone tinnitus, and 6 had short periods of suppression. This seems very drastic to us.
A small phase 1 trial recently published in the journal of Neurosurgery found (in only 5 participatnts), that 3 had a significant decrease in tinnitus for a trial of deep brain stimulation around the caudate nucleus (Cheung et al, 2019). This is not a currently approved treatment, and but we can hope that this approach might develop into a more practical treatment for very severe cases.
There are numerous devices and medications for tinnitus that are probably placebos. See this page for more discussion. If a placebo works for you - - that's wonderful !
Again, bad news. Surgery should be considered when there is a clear structural reason for tinnitus that can be improved with surgery. It is also worth considering if hearing can be improved by surgery. Generally though, hearing aids or implantable devices are much more successful than surgery.
Diet: We recommend that persons with tinnitus limit salt (no added salt), and refrain from drinking caffeinated beverages, other stimulants (like tea), and chocolate. The salt restriction is intended for those who might have a subclinical form of Meniere's. Caffeine and similar substances may increase tinnitus in a nonspecific fashion but the effect size is small, and this is really a trial/error thing. Otherwise the diet should be balanced and have normal amounts of fruits and vegetables. There is some evidence for reduced carbs being helpful, probably part of the general rule that healthier people have less tinnitus. There are a few papers suggesting that B12 supplements help (if your blood levels are low).
Alternative medicine approaches. Ginkgo-Biloba, betahistine (Serc), Zinc, and acupuncture are sometimes advocated as treatment for intractable tinnitus. There is little evidence that these agents work, but they also do not seem to be harmful. More discussion about alternative medications for Meniere's disease is available here.
Psychological help: Often, anxiety or depression which accompanies tinnitus may be as big a problem as the tinnitus itself. In this instance, consultation with a psychologist or psychiatrist expert in this field may be helpful. This is not so easy though as very few counselors specialize in tinnitus, and patients often know more than their clinicians. The "no discussion treatment" approach has some positives too -- if you can ignore tinnitus rather than obsess about it, this may be the best way to handle it rather than participating in psychological treatments that involve discussing one's tinnitus for an hour every week. Rationally, the choice of treatment should depend on personality style and ones ability to suppress unwanted thoughts.
- CBT (cognitive behavioral therapy) is presently favored by the counselors. However, we think that this should be combined with rational use of medications (such as antidepressants and sleep medication), so a counselor should not be attempting to "go it alone", at least in severe situations.
- Hypnosis may be effective and increase tolerance to tinnitus, but randomized controlled trials are not encouraging (Dobie, 1999).
- Internet based psychological treatments have been available for about 15 years, and have considerable promise (Andersson et al, 2015). This is another method of delivering CBT.
- Medications that help people with obsessive compulsive disorder (such as the SSRI family) may be helpful.
In general, while we rarely send patients for conselling right now in our clinical practice, we do favor prescribing a simple SSRI (such as citalopram) and and a weak anxiety/sleep medication (such as klonazepam) for persons with acute and "catastrophic" tinnitus, as these people can be sleep deprived, anxious, miserable and depressed. This is aimed both at improving sleep and reducing anxiety, as both of these factors make tinnitus even worse. We aim to stop the medication in most in 3 months.
Tinnitus Retraining Therapy (TRT) is a method of treating tinnitus helpful for some (Wang et al, 2003). It requires a considerable commitment of time, and health insurance in the USA considers it to be a type of psychotherapy (see above). TRT combines counseling and sound therapy. Sound therapy (masking) can now be obtained through cellphone "apps", and thus the main value of the TRT program as of 2020 is the psychotherapy piece as well as oversight by an experienced practitioner. According to the inventor of TRT, the goal of counseling is to reclassify tinnitus into the category of a neutral stimulus. The goal of sound therapy is to decrease the strength of tinnitus-related neuronal activities (Jastreboff, 2015). Of course results are what count. Jastreboff stated that "The majority of these publications indicate TRT offers significant help for about 80 % of patients." Other reviews are less enthusiastic however.
We sometimes refer patients for TRT, but the time required and general lack of health insurance support for long term psychotherapy are significant barriers.
Self Help: You might consider joining the American Tinnitus Association. (PO Box 5, Portland, OR 97207, 503-248-9985). However, if your tinnitus has been well "worked up", and there is nothing more to be done, it might be best to attempt to ignore it rather than focus more attention on it. Joining of these sorts of organizations intrinsically draws more attention to ones illness.
As of 8/2012, a visit to the National Library of Medicine's search engine, Pubmed, revealed more than 3,000 research articles with tinnitus in their title, published. In spite of this gigantic effort, very little is presently known about tinnitus, and effective treatment is generally unavailable.
Plein et al (2015) suggested that the quality of published studies concerning clinical trials for tinnitus were suboptimal, and in fact, only 20% of 147 had a low risk of bias. The author of this page feels happy that at least someone is doing trials on this difficult situation ! Any kind of trial is better than no effort at all.