For patients
Idiopathic tinnitus is difficult to manage. A broad range of drug and non-drug treatments have been explored, but none has yet proven to be superior to sham treatment. Strategies such as tinnitus masking appear to help cope with idiopathic tinnitus, but this approach requires willingness and patience.
For practitioners
Introduction
Tinnitus is said to affect about 37 million Americans, and approximately 0.5% of the population has disabling tinnitus. Most cases of tinnitus have no identifiable cause. Unfortunately, critical reviews of the available evidence for the various treatments have been unencouraging (Dobie 1999, Seidman and Keate 2002), noting that no pharmacotherapies are well supported by rigorous, prospective, double-blinded, placebo-controlled trials (Kim, Kim et al. 2021).
Pharmacologic approaches
A broad array of conventional and unconventional pharmacotherapies has been tried as treatment for tinnitus. We discuss here the ones about which patients ask most commonly.
Some papers suggest that a range of pharmacotherapies have efficacy in tinnitus (Seidman and Babu 2003). But most reviews are less optimistic, and usually conclude that no pharmacotherapies are effective for tinnitus (Patterson and Balough 2006, Kim, Kim et al. 2021).
Benzodiazepines such as clonazepam (Gananca, Caovilla et al. 2002) are often used in the treatment of tinnitus. Whether these drugs actually diminish tinnitus, or simply alleviate the anxiety that tinnitus provokes, is unclear.
Reviews of the very few randomized trials of various antidepressants as treatment for tinnitus concluded that there is insufficient evidence to support the contention that antidepressant therapy improves the tinnitus itself (Baldo, Doree et al. 2006).
There has been a single prospective, double-blind, placebo-controlled study of acamprosate for the treatment of tinnitus (Azevedo and Figueiredo 2005), and although this treatment has been discussed subsequently by the same authors (Azevedo and Figueiredo 2007), the results have not been replicated.
Alternative approaches
One prospective, randomized, placebo-controlled study concluded that zinc may be a useful treatment for tinnitus (Arda, Tuncel et al. 2003). However, the study was small (28 patients), and the criteria for a positive response were unimpressive (decrease in tinnitus volume of 10 dB; decrease of 1 point on a subjective tinnitus questionnaire on a scale of 0-7). In our view, these data are too weak to demonstrate the superiority of zinc over placebo.
Cochrane reviews consistently conclude that there is insufficient evidence that ginkgo biloba is superior to placebo (Hilton and Stuart 2004, Sereda, Xia et al. 2022).
One component extracted from ginkgo biloba is a compound called EGb 761 (marketed as “Arches Tinnitus Formula®” and “Tebonin Forte®”). One review article (Holstein 2001) covered 19 trials of this drug. Of those studies, only 5 were randomized, double-blind, placebo-controlled trials. Of those 5 trials, 2 examined tinnitus in the context of vascular disease, and another 2 examined patients who had tinnitus and concomitant vestibular symptoms. Only 1 randomized, double-blind, placebo-controlled trial examined patients with tinnitus. The authors of that study, originally written in German, eventually published results in English as well (Morgenstern and Biermann 2002). The study’s primary end point was “change in tinnitus volume in the more severely affected ear during randomized treatment.” The structure of the trial was unusual in that all patients first received 10 days of inpatient infusion of the compound before being randomized to receive either oral drug or oral placebo – in other words, the trial was not entirely placebo-controlled since no patient received exclusively placebo. The study was also troubling in that only 36.7% of patients completed the study. The study concluded, “the absolute treatment group difference was moderate.” As of this writing there are no similar studies in PubMed. However, a randomized, double-blind, placebo-controlled study and meta-analysis of prior studies (Rejali, Sivakumar et al. 2004) concluded that EGb 761 was no better than placebo.
Non-pharmacologic approaches
Tinnitus masking essentially involves listening to sounds in such a fashion that tinnitus fades into the background and becomes less noticeable. There are enthusiastic supporters of this approach (Aytac, Baysal et al. 2017), though Cochrane reviews have consistently concluded that there is not yet sufficient evidence to prove the efficacy of masking (Hobson, Chisholm et al. 2010, Hobson, Chisholm et al. 2012).
Tinnitus retraining involves changing one’s own reaction to tinnitus, and as such is a type of cognitive-behavioral therapy.
A randomized trial comparing tinnitus masking with tinnitus retraining found that the effect of tinnitus masking is fairly constant over time, while tinnitus retraining is incremental. Consequently, for patients with a severe tinnitus problem, tinnitus masking provides the greatest benefit at 3 months (Henry, Schechter et al. 2006), though this improvement is surpassed by the benefit of tinnitus retraining at 12 and 18 months (Henry, Schechter et al. 2006). Prior comparative studies found similar results (Wang, Jiang et al. 2002).
The rationale underlying tinnitus retraining is that tinnitus, whatever its cause, becomes bothersome only if it is associated with negative emotions, and that it is possible to “retrain” a person’s reaction to tinnitus, thereby promoting habituation to the point that the tinnitus is no longer bothersome (McFerran and Phillips 2007). This approach has been pursued by Jastreboff (Jastreboff 2007, Jastreboff 2008) and others (Hazell and Sheldrake 2008).
Various studies, mostly uncontrolled, and largely funded by the companies that manufacture the devices being tested, have suggested that different kinds of sounds provide variable degrees of relief from tinnitus (Henry, Rheinsburg et al. 2004). This has led to the development of what are basically “customized” masking strategies. For example, Neuromonics® has developed a “program” (Neuromonics 2008) that involves an audio device that costs $5000. The company funded research on this program. One study examined two different protocols of the Neuromonics program, though did not compare them to placebo, yet concluded that the program is extremely “rapidly and profoundly effective” (Davis, Paki et al. 2007).
A randomized, placebo-controlled trial of transcutaneous electrical stimulation showed no benefit (Kapkin, Satar et al. 2008).
Reviews of prospective studies of hyperbaric oxygen therapy found no conclusive evidence that this approach is better than placebo (Desloovere 2007), even for tinnitus associated with sudden hearing loss (Bennett, Kertesz et al. 2005, Bennett, Kertesz et al. 2007).
Numerous studies have explored whether acupuncture helps tinnitus. Study results are mixed; while some suggest efficacy (Okada, Onishi et al. 2006, Rogha, Rezvani et al. 2011, Doi, Tano et al. 2016, Laureano, Onishi et al. 2016, Liu, Han et al. 2016, Kim, Kim et al. 2017, Naderinabi, Soltanipour et al. 2018), more suggest that acupuncture is not superior to sham treatment (Park, White et al. 2000).
There are emerging data regarding the use of biofeedback in the control of tinnitus (Dohrmann, Weisz et al. 2007).
There are also emerging data on the use of transcranial magnetic stimulation (TMS). Some placebo-controlled trials suggest that TMS is effective (Eichhammer, Langguth et al. 2003, Kleinjung, Eichhammer et al. 2005, Folmer, Carroll et al. 2006, Kleinjung, Steffens et al. 2006, Langguth, Kleinjung et al. 2007, Rossi, De Capua et al. 2007, Smith, Mennemeier et al. 2007, Meeus, Blaivie et al. 2009, Anders, Dvorakova et al. 2010, Marcondes, Sanchez et al. 2010, Mennemeier, Chelette et al. 2011, Vanneste, Plazier et al. 2011, De Ridder, Song et al. 2013, Lee, Yoo et al. 2013, Lehner, Schecklmann et al. 2013, Yilmaz, Yener et al. 2014, Folmer, Theodoroff et al. 2015, Wang, Li et al. 2015, Piccirillo 2016, Wang, Li et al. 2016, Cacace, Hu et al. 2017, Theodoroff, Griest et al. 2017), while other placebo-controlled trials find TMS to be no better than placebo (De Ridder, De Mulder et al. 2007, Piccirillo, Garcia et al. 2011, Plewnia, Vonthein et al. 2012, Hoekstra, Versnel et al. 2013, Piccirillo, Kallogjeri et al. 2013, Engelhardt, Dauman et al. 2014, Langguth, Landgrebe et al. 2014, Roland, Peelle et al. 2016, Landgrebe, Hajak et al. 2017, Sahlsten, Virtanen et al. 2017).
Some putative treatments for tinnitus focus on psychological approaches (Tyler, Gogel et al. 2007, Battaglino 2008, Fuller, Cima et al. 2020).
Some imaginative approaches have been explored, such as electrical stimulation of the tongue (Hamilton, D’Arcy et al. 2016, Conlon, Hamilton et al. 2019, Abbasi 2020, Conlon, Langguth et al. 2020), but this remains investigational.
Combination approaches
A review of available randomized trials found that general counseling, as well as antidepressants (specifically, tricyclics such as amitriptyline or nortriptyline), may be helpful (Dobie 1999) in coping with tinnitus, even if they do not change the underlying pathobiology of the disease.
Some approaches involve masking in conjunction with counseling (Tyler, Gogel et al. 2007). Others involve even more elaborate approaches of counseling, psychology, hypnosis and pharmacotherapy (Hogan 2008).
Practical advice for patients with tinnitus
Although there is not yet any solid evidence for a treatment that actually eliminates idiopathic tinnitus, that does not mean that there is nothing to do about it. We generally encourage patients to consider consultation with a tinnitus audiologist for tinnitus masking and tinnitus retraining, as there is modest evidence supporting these approaches, and they incur no medical risk. Other simple strategies include (Hain 2008):
1. Avoid exposure to loud noises and sounds.
2. Decrease your intake of salt.
3. Avoid stimulants such as caffeine and nicotine.
4. Exercise daily, get adequate rest, and avoid fatigue.
5. Avoid ototoxic medications known to increase tinnitus such as aspirin, non-steroidal anti-inflammatory drugs, and quinine-containing preparations.
6. If you feel ready to experiment with masking strategies, try a variety of sounds (different kinds of music, television static, sea waves, waterfalls, nature sounds). When you find a sound, or a combination of sounds, that is pleasant and distracts you from your tinnitus, try listening to it whenever possible, particularly when your environment would otherwise be quiet (i.e., when there is low ambient noise). Patients usually ask, “How long do I need to do this?” There is no answer to that question, but the general trend is that the more frequently and the longer you listen to distracting sound, the more likely it is that you will be able to ignore tinnitus – eventually even when the distracting sound is no longer present.
7. If you are having difficulty coming up with a masking strategy, see an audiologist for further advice. In some cases a special type of audiogram can be performed that tries to characterize the pitch and loudness of your tinnitus, and based on that information the audiologist may be able to recommend a particular strategy.
8. If you feel depressed, ask your physician about treatment options. Even if the tinnitus is the root cause of the depression, there is nothing wrong with treating the depression independently while you are trying to bring the tinnitus under better control.
9. If you fear that you will kill yourself or someone else, seek help promptly.
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