Therapy and Treatment Options

The perceived intensity of tinnitus can fluctuate depending on many factors — including the patient’s overall well-being. There are simple things patients can do that may alleviate some of the burden.

Patients can engage in lifestyle and wellness activities to improve the perceived intensity of their tinnitus. General wellness does not have a direct impact on the causes or biology of tinnitus, but it can provide strong peripheral benefits that make living with tinnitus feel much easier.

Below is a list of general wellness activities for tinnitus patients to consider.

Diet

There is scant evidence directly connecting specific foods (or the exclusion of specific foods) to improved tinnitus symptoms. However, it is beyond question that a healthy diet has myriad beneficial effects on the body, which may lessen the impact of tinnitus. A health-conscious diet can reduce hypertension and weight, increase blood flow, heighten energy levels and improve emotional well-being — all of which can benefit your tinnitus.

Patients with tinnitus and Ménière’s Disease may want to explore a low-salt diet, as there is a very strong correlation between salt consumption and Ménière’s symptoms.

One diet-related tinnitus issue that receives a lot of discussion is the consumption of caffeine. There is very little scientific evidence that shows caffeine exacerbates tinnitus symptoms. That being said, tinnitus patients should track their own experience with caffeine and adjust accordingly. If caffeine seems to significantly amp-up your tinnitus, then consider reducing your consumption; if caffeine has no impact and/or is an enjoyable part of your daily routine, then you may want to continue consumption as normal. (This general rule is true for most other dietary considerations, including alcohol.)

Physical Activity

Exercise isn’t only good for your physical body — it’s also good for your emotional well-being and can help minimize the burden of tinnitus. Exercise reduces stress, a known exacerbant for tinnitus.

Social Activity

Many tinnitus patients report feelings of social isolation, due to difficulties with interpersonal communication, sound sensitivity, and/or irritability. Unfortunately, removing yourself from social situations creates a cycle of negative reinforcements that may make tinnitus an even larger problem. (Isolation causes patients to focus more on their tinnitus, which then makes it less likely that they’ll socialize, which further focuses attention on tinnitus, and so on.)

Social experiences with friends, family, and peers can positively distract patients from their tinnitus symptoms. They can also improve emotional wellness, general feelings of contentment and optimism. Moreover, sharing your experience of tinnitus with others can help you develop a peer support network that may help you through your next tough patch.

Recreational Activities and Hobbies

Some patients believe that having tinnitus means they must give up activities that they enjoy. That is absolutely not the case. Patients can and should continue activities that make them happy and which provide positive diversions from a focus on tinnitus.

Some activities may even provide the benefit of directly masking the sound of tinnitus. Many bicyclists report that the sound of wind passing by their ears while riding covers their tinnitus perception. (Of course, each patient is different and a sound that is masking for one person may be an annoyance for another.)

Tinnitus patients may need to make some minor adjustments or take certain precautions prior to engaging in specific recreational activities — particularly activities that involve loud noise. Patients should consult their hearing health professional on the appropriate hearing protection for these activities.

Stress Reduction

Several of the options listed above have the benefit of reducing stress. In general, any activity that lowers stress may also lessen the intensity of tinnitus symptoms. In addition to diet, exercise, and socialization, patients can explore other avenues to relaxation, including meditation.

Biofeedback

Biofeedback is relaxation technique that teaches patients to control certain autonomic body functions, such as pulse, muscle tension, and skin temperature. The goal of biofeedback is to help people manage stress and anxiety by changing the body’s reaction to these negative influences. Biofeedback is used for a variety of different chronic conditions and many tinnitus patients notice a reduction in symptoms when they are able to control stress.

Hypnotherapy

Hypnotherapy has been shown to promote relaxation and reduce anxiety. It may also alter neural connections between areas of the brain. As such, it is often positioned as a good wellness option for patients with tinnitus.

Hearing Protection

Many patients, particularly those with extreme sound sensitivity, may find some relief through the use of personal hearing protection. Ear muffs, ear plugs, canal caps, and other sound mufflers can protect from painful sounds and future damage to the auditory system.

While the use of proper hearing protection is encouraged, it should be noted that protective equipment does not reverse the symptoms of tinnitus. Additionally, because these products block external, ambient noise, some patients may perceive that their tinnitus gets louder when wearing hearing protection.

Tinnitus can be associated with conditions that occur in all areas of the auditory system, including external (earwax), middle ear (ear infection, otosclerosis, vascular problems), and inner ear (circulatory disorders, noise-induced hearing loss, ototoxic medications).

To rule out an underlying medical condition, such as tumors (rare) and Ménière’s disease, it is normal to see an otolaryngologist (ear, nose, and throat doctor) for evaluation. Because approximately 90 percent of patients with tinnitus have some degree of hearing loss, it is common to have an audiogram (hearing test). An audiological exam may yield information about the cause of tinnitus as well options for treatment.

An audiologist is trained to identify, diagnose, and manage or treat disorders of the auditory (e.g., hearing loss and tinnitus) and vestibular systems (e.g., dizziness). As part of a treatment program, audiologists may recommend hearing aids to make day-to-day listening easier, improve awareness, and help with tinnitus. Some audiologists may also have additional training in the specialized evaluation and management of tinnitus and provide services such as Tinnitus Retraining Therapy, Tinnitus Activities Treatment, Progressive Tinnitus Management, etc.

Audiologists hold either a master's’ (M.A. or M.S.) or doctorate (Au.D. or Ph.D.) degree in audiology. Audiologists work predominantly in private practices, otolaryngology (ENT) practices, academic medical centers and hospitals.

There are currently no FDA-approved drugs specifically for tinnitus. However, there are pharmacological options to address the stress, anxiety, and depression that are caused by (and can sometimes exacerbate) tinnitus.

There are no medications that have been shown to reverse the neural hyperactivity that is thought to cause tinnitus. Drugs cannot cure tinnitus, but they may provide relief from the negative distress caused by severe tinnitus.

Patients should consult their healthcare providers for guidance on medications that may be appropriate for their situation. Not all drugs are effective or appropriate for all patients. Moreover, the introduction of any drug can result in undesired side effects and/or counteract existing prescription drug treatments.

Antidepressants and Antianxiety Drugs

The medications most often used in tinnitus management are psychoactive drugs that treat the behavioral issues related to tinnitus. These drugs can help relieve the stress, anxiety, and depression related to tinnitus, minimizing the psychological burden of the condition. Because there is a circular relationship between negative emotions and tinnitus (tinnitus causes anxiety, which makes tinnitus seem worse, which causes more anxiety...) psychoactive drugs may make tinnitus itself less noticeable for some patients.

Common antidepressant drugs used in relation to tinnitus include:

• Clomipramine (Anafranil)
• Desipramine (Norpramin)
• Imipramine (Tofranil)
• Nortriptyline (Pamelor)
• Protriptyline (Vivactil)

Commonly used antianxiety medications include:

• Alprazolam (Xanax)
• Clonazepam (Klonopin)
• Diazepam (Valium)
• Lorazepam (Ativan)

Again, antidepressants and antianxiety drugs may help to alleviate the emotional and psychological burden of tinnitus for some patients, but they do not appear to impact tinnitus itself. Research shows very limited efficacy in patients without anxiety, depression, or obsessive-compulsive disorder.  Moreover, some research suggests that antidepressants and antianxiety medications may reduce neural plasticity, making it harder for patients to naturally habituate to tinnitus over time. However, for patients with significant behavioral issues, psychoactive drugs may provide beneficial relief.

Off-Label Medications

“Off-label” refers to any medication that is being used for a purpose other than what it has been approved for by the U.S. Food and Drug Administration (FDA). An array of drugs has been anecdotally used off-label for tinnitus relief. These include antihistamines, anticonvulsants, anesthetics, and even anti-alcohol drugs. However, there is very little scientific evidence illustrating that any of these medications provide measurable tinnitus improvement.

Over-the-Counter Drugs and Supplements

A number of over-the-counter substances (pills, powders, herbs, drops, etc.) are misleadingly marketed as “tinnitus remedies” and even "miracle cures." There is no reliable scientific evidence that these products — or the ingredients within them — have any impact on tinnitus. While there may be anecdotal success stories about these products, any reported improvements are likely due to a short-term placebo effect. Patients should beware of these products, as they are not fully regulated for safety by the FDA and have no scientifically measurable effect.

Drug Development

The search for a drug-based cure for tinnitus is one of the most robust areas of research, with several major biopharmaceutical firms investing heavily towards this goal. While this bodes well for new drug developments in the future, it is impossible to estimate if/when a broadly effective, patient-ready tinnitus medication will be available on the market.

Considerations

Side effects: Most prescription drugs include some possible undesirable side effects. Patients should work with their healthcare provider to determine whether the potential benefit of a drug outweighs the possible side effects.

Drug interactions: Some medications may counteract prescriptions the patient is taking for another medical condition. Patients should consult their healthcare provider to determine the best medication for their unique medical situation.

Reduced neural plasticity: Some psychoactive drugs may reduce the brain’s natural ability to adapt and change, making it more difficult for a patient to habituate (learn to ignore) the sound of their tinnitus.

Medical supervision: Psychoactive drugs are very powerful medications and should only be used under regular supervision from a trained healthcare professional. Patients should not start, stop, or modify their dosage or schedules without first consulting their healthcare provider.

References

Baldo, P., Doree, C., Molin, P., McFerran, D. and Cecco, S. (2012) “Antidepressants for Patients with Tinnitus.” Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD003853. DOI: 10.1002/14651858.CD003853.pub3.

Folmer, R.L., Theodoroff, S.M., Martin, W.H., Shi, Y. (2014) “Experimental, Controversial and Futuristic Treatments for Chronic Tinnitus.” Journal of the American Academy of Audiology, 25:106-125.

Hilton, M.P., Zimmermann, E.F. and Hunt, W.T. (2013) “Ginkgo Biloba for Tinnitus.” Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD003852. DOI: 10.1002/14651858.CD003852.pub3.

Hoekstra, C.E.L., Rynja, S.P., van Zanten, G.A. and Rovers, M.M. (2011)  “Anticonvulsants for Tinnitus.” Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD007960. DOI: 10.1002/14651858.CD007960.pub2.

Salvi, R., Lobarinas, E., and Sun, W. (2009) “Pharmacological Treatments for Tinnitus: New and Old.” Drugs of the Future, 34(5): 381–400.

Hearing Aids

Hearing aids can be classified as a type of sound therapy because they augment external noise as a way of increasing auditory stimuli and diverting attention from the perception of tinnitus. People often mistake that loud tinnitus, rather than hearing loss, interferes with their hearing. It is therefore critical to have one’s hearing evaluated since as many as 90 percent of people who experience chronic tinnitus also have hearing loss.

Kim, D.K., Park, S.N. Kim, Son, H.R., et al. (2011) Prevalence and significance of high-frequency hearing loss in subjectively normal-hearing patients with tinnitus. Annals of Otology, Rhinology, and Laryngology, 120(8), 523–528.

To learn more about distinguishing between hearing loss, tinnitus, and hyperacusis, and the recommended protocols for evaluation, click here.

Hearing Aids

Tinnitus is overwhelmingly connected to some level of hearing loss. Augmenting the reception and perception of external noise can often provide relief from the internal sound of tinnitus.

Most patients develop tinnitus as a symptom of hearing loss, caused either by age, long-term hearing damage, or acute trauma to the auditory system. According to the general scientific consensus, hearing loss results in less external sound stimuli reaching the brain. In response, the brain undergoes neuroplastic changes in how it processes different sound frequencies. Tinnitus is the product of these maladaptive neuroplastic changes.

Patients with hearing loss and tinnitus may find relief from the use of hearing aids and other sound amplification devices. Hearing aids are small electronic devices worn in or behind the ear. Using a microphone, amplifier, and speaker, hearing aids supplement the volume of outside noise and increase the amount of sound stimuli received and processed by the body’s auditory system.

In a 2007 survey of hearing health professionals, respondents self-reported that roughly 60% of their tinnitus patients experienced at least some relief when wearing hearing aids; roughly 22% patients found significant relief.

Hearing aids can be effective for several reasons:

Masking and Attentional Effects

Hearing aids can augment the volume of external noise to the point that it covers (masks) the sound of tinnitus. This makes it more difficult to consciously perceive tinnitus and helps the brain focus on outside, ambient noises. The masking impact of hearing aids is particularly strong for patients who have hearing loss in the same frequency range as their tinnitus.

Auditory Stimulation

Increasing the volume of external noise also increases the amount of auditory stimulation received by the brain. There may be benefits to stimulating the brain’s auditory pathways with soft background sounds that might not otherwise be heard.

Improved Communication

Hearing aids help by augmenting the external volume so that it’s easier to hear conversations and surrounding sounds. As a result, patients may feel less personal frustration and social isolation.

To better understand how hearing aids can help with tinnitus, consider the two images below as simple visual representations of tinnitus and hearing loss. Imagine that the cricket represents a person’s tinnitus, and the background image represents background sounds.

A

B

In Picture A, the person has a hearing loss. The background sound is indistinct, and the cricket (tinnitus) is very clear. In Picture B, the person has been fitted with a hearing aid, and the background is clear and rich in detail. Although the cricket (tinnitus) is still present, it blends into the background. The listener’s attention is diverted to other aspects of environmental sound. The success of hearing aids in managing tinnitus depends on how well background sounds can be made to blend with tinnitus.

Modern digital hearing aids, with open-fit designs and patient-customized hearing loss profiles, may be particularly useful for managing tinnitus. Moreover, many newer hearing aids include supplemental sound masking functionality (white noise or other artificial ambient sound played directly into the ear) that further covers the perception of tinnitus.

Like most tinnitus treatments, hearing aids may work best when paired with a structured tinnitus education program and some form of patient counseling.

Cochlear Implants

Cochlear implants, surgically implanted devices that restore the sensation of sound to deaf patients or those with severe hearing loss, are another form of sound amplification that may be useful in alleviating tinnitus symptoms. These work on the same principle as hearing aids — they increase outside sound stimulation, helping to distract the brain from the sounds of tinnitus. Cochlear implants are generally available only to patients who have severe hearing loss that prevents understanding spoken communication, limited benefit from hearing aids, as determined by an audiologist, and no medical conditions/factors that would increase the risks associated with cochlear implants..

Considerations

Price: Hearing aids can be expensive and are often not covered by insurance plans. Tinnitus patients with negligible hearing loss may find it difficult to find insurance coverage for hearing aids.

Lifestyle and Comfort: Research suggests hearing aids are most effective when they are used consistently during waking hours. This requires the patient to wear the devices on a full-time basis.

Sound Sensitivity: Patients with hyperacusis or other forms of sound sensitivity may encounter some discomfort when using sound amplifying devices.

Age: While hearing aids may benefit most patients, some studies suggest that they are most effective for younger patients and those with a shorter history of tinnitus.

References

Del Bo, L. and Ambrosetti, U. (2007) “Hearing Aids for the Treatment of Tinnitus.” Progress in Brain Research, 166: 341-345.

Folmer, R.L., Theodoroff, S.M., Martin, W.H., Shi, Y. (2014) “Experimental, Controversial and Futuristic Treatments for Chronic Tinnitus.” Journal of the American Academy of Audiology, 25:106-125.

Hoare, D.J., Edmondon-Jones, M., Sereda, M., Akeroyd, M.A.and Hall, D. (2013) “Amplification with Hearing Aids for Patients with Tinnitus and Co-Existing Hearing Loss.” Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD010151. DOI: 10.1002/14651858.CD010151.pub2.

Hoare, D.J., Searchfield, G.D., Refaie, A.E. and Henry, J. (2014) “Sound Therapy for Tinnitus Management: Practicable Options.” Journal of the American Academy of Audiology. 25: 62-75.

Kochkin, S and Tyler, R. (2008) “Tinnitus Treatment and the Effectiveness of Hearing Aids: Hearing Care Professional Perceptions.” Hearing Review, Available at: http://www.hearingreview.com/2008/12/tinnitus-treatment-and-the-effectiveness-of-hearing-aids-hearing-care-professional-perceptions/  (Accessed March 25, 2015.)

Searchfield, G. (2005) “Modern Hearing Aids - A Help for Tinnitus.” Tinnitus Today, 30,2: 14-16.

Shekhawat, G.S., Searchfield, G.D., and Stinear, C.M. (2013) “Role of Hearing Aids in Tinnitus Intervention: A Scoping Review.” Journal of the American Academy of Audiology. 24(8):747-62.

Trotter, M.I and Donaldson, I. (2008) “Hearing Aids and Tinnitus Therapy: A 25-Year Experience.” The Journal of Larnygology and Otology, 122: 1052-1056.

Sound Therapies

Tinnitus is a non-auditory, internal sound. But patients can use external sound to counteract their perception and reaction to tinnitus. Sound masking can cover the sound of tinnitus, while more advanced therapies may provide more robust relief.

“Sound therapy” is a broad term that may be used in many ways, depending on the specific product, clinical setting, or individual clinician. In general, sound therapy refers to the use of external sound to alter a patient’s perception of, or reaction to, tinnitus. Like other tinnitus treatments, sound therapies do not cure the condition, but they may significantly lower the perceived burden and intensity of tinnitus.

Sound-based therapies function on four general mechanisms of action. (Mechanisms of action are the putative processes, or reasons why, a given intervention is effective.) Different products may emphasize a specific aspect, or include a combination of approaches:

• Masking: exposing the patient to an external sound at a loud enough volume that it partially or completely covers the sound of their tinnitus
• Distraction: using external sound to divert a patient’s attention from the sound of tinnitus
• Habituation: helping the patient’s brain reclassify tinnitus as an unimportant sound that can and should be consciously ignored
• Neuromodulation: the use of specialized sound to minimize the neural hyperactivity that is thought to be the underlying cause of tinnitus

There are many devices that offer different levels of sound therapy. Below is a list of general types of sound therapy products, and a discussion of their specific mechanisms of action and reported efficacy.

Sound Masking Devices

These are devices or applications that provide generic background noise — often white noise, pink noise, nature sounds or other ambient, subtle sounds. The sound generated by sound machines can partially or fully mask a patient’s perception of tinnitus, providing relaxation and temporary respite from the condition.

The “traditional” sound masker is a single-function table-top or bedside device with several pre-set sound options. However, almost any sound-producing device can be used for masking purposes, including personal media players, computers, radios, and televisions. Even electric fans or table fountains can provide masking sounds. In general, the most effective masking sounds are those that elicit positive emotional responses in the patient.

Sound masking devices are typically only effective during or immediately after active use; they have very limited long-term effectiveness in reducing the overall perception of tinnitus.

Modified-Sound / Notched-Music Devices

While commercial-grade sound machines deliver a generic sound selection, a variety of medical-grade devices provide more customized sounds designed around the patient and his/her tinnitus. These devices play special notched-music or algorithmically-modified sounds in which specific frequencies and tones are emphasized — often at a level not consciously perceivable by the listener. The reported function of these modified sounds varies according to the specific product.

Unlike standard white noise machines, notched-music devices are generally worn intermittently (only during defined therapy sessions or times of predictable acute need, such as before bed or immediately upon waking), and provide lingering benefit after the device is turned off.

Also, unlike standard white noise machines, notched-music and modified sound devices may, over time, alleviate the perceived burden of tinnitus — even after they are turned off. By facilitating habituation, these products may help the patient naturally “tune out” the perception of tinnitus.

The reported clinical efficacy of modified-sound and notched-music devices varies by product, but in general these devices appear to provide some level of relief to many patients. Optimal results typically require at least some patient counseling and education in addition to the use of sound devices.

Combination Devices

Many hearing aids now come with integrated sound generation technology that delivers white noise or customized sounds to the patient on an ongoing basis. These devices combine the benefits of a hearing aid with those of other sound therapies and are particularly well suited for tinnitus patients with measurable hearing loss. Also, because of the portable nature of these devices, they can provide semi-continuous use and more consistent benefit throughout the day.

The efficacy of these combination devices varies, depending on the device, the integrated sound feature, and the particular patient. And, although research data is not definitive, the professional consensus seems to be that hearing aids with integrated sound generators benefit a significant number of patients.

Sound and Sleep Apps

With countless apps and little direction, it can be hard to figure out which sound and sleep apps might help with tinnitus and/or getting a good night’s sleep. By clicking in the image below, you’ll find a list of sound and sleep apps, many of which are free, that were compiled by an audiologist based on patient feedback. The apps are available through Apple’s App Store and under Google Play’s App section.

Considerations

• Price: Hearing aids and medical-grade sound therapy devices can be expensive and are often not covered by insurance plans.
• Tinnitus Symptoms: Patients should consider their lifestyles and the times when they most require relief from their tinnitus. If tinnitus is mostly an issue immediately before or during sleep, a bedside white noise machine may be sufficient; if tinnitus is an ongoing, 24/7 concern, a more portable option may be preferable.
• Sound Sensitivity: Patients with hyperacusis or another form of sound sensitivity may encounter some discomfort when using sound amplifying devices.
• Education and Support: Nearly all sound therapy systems work best when they are coupled with a program of supplemental patient education and counseling.

References

Hoare, D.J., Searchfield, G.D., Refaie, A.E. and Henry, J. (2014) “Sound Therapy for Tinnitus Management: Practicable Options.” Journal of the American Academy of Audiology. 25: 62-75.

Hobson, J., Chisholm, E., El Refaie, A. (2012) “Sound Therapy (Masking) in the Management of Tinnitus in Adults.” Cochrane Database of Systematic Reviews, Issue 11. Art. No.: CD006371. DOI: 10.1002/14651858.CD006371.pub3.

Tinnitus can trigger strong, negative emotions, including anxiety, depression, and anger. Patients can learn to control their emotional reactions and thereby disassociate tinnitus from burdensome negative behavioral responses.

Cognitive (adj. form of cognition) — involving or related to the functions of attention, knowledge, memory, judgement, reason, and decision-making

Behavioral — involving or related to physical, emotional, and psychological action

Behavioral therapies, which focus on the patient’s emotional reaction to tinnitus, are among the best established and most effective treatments for burdensome tinnitus. These approaches have consistently been shown to reduce tinnitus-related distress, anxiety, and depression, and to improve the overall quality of life for patients.

The rationale of behavioral treatments is that “severe” tinnitus is defined by its emotional toll, not its acoustic characteristics. (Research shows that there is little correlation between tinnitus loudness/pitch and patient-reported distress.) What makes the condition truly burdensome are the negative psychological and cognitive reactions patients have in response to tinnitus. In other words, the patient’s emotional response is the key factor in whether the tinnitus is perceived as bothersome or non-affective, deeply distressing or a minor annoyance. The goal of behavioral therapies is to help patients control their reactions to tinnitus, and thereby reduce the perceived impact of the condition.

Patients who pay close attention to their tinnitus and who lack emotional coping techniques are generally more depressed, more distressed, and have higher perceived handicaps related to their condition. Behavioral therapies provide skills to reduce attention to tinnitus, improve coping, and devise alternative thinking and behavior patterns that help patients alleviate the negative impact of tinnitus on day-to-day living. The overall objective of therapy is to increase pleasant activities, learn relaxation techniques, reduce monitoring of tinnitus, and build cognitive skills that replace negative (or unhelpful) thinking.

Therapy can be delivered individually, in group-settings, online, or through teletherapy sessions. There is growing evidence that therapy delivered through virtual conferencing, online, or on the telephone is as effective as in-person; but it depends on the patient and his/her needs. From an accessibility standpoint, telehealth makes it easier to access help. However, not all insurance plans cover it.

The outcomes evidence for behavioral tinnitus therapies are robust. A 2010 meta-analysis of eight research studies showed significant improvement in self-reported depression and quality of life for patients completing a therapy program. A 2014 review of research literature showed that these treatments consistently and significantly decreased tinnitus severity and impairment, reduced tinnitus-related fear, and lowered general depression and anxiety.  Moreover, the patient improvements after psychological therapy were found to be stable and long lasting — with benefits continuing as long as 15 years after the end of treatment.

On this page, we are using “behavioral therapy” as an umbrella term for a variety of different tinnitus treatments. While these individual practices may have slight variations (depending on the protocol or even individual clinician) they all generally include: patient education, analysis of emotional triggers, exploration of the patient’s thoughts and beliefs about tinnitus, applied relaxation techniques, investigation of the patient’s emotional reactions to tinnitus, and an assessment of the patient’s avoidance behaviors.

Cognitive Behavioral Therapy (CBT)

This is the generalized treatment term used to address a variety of issues, including the negative emotions associated with tinnitus. Many clinicians, particularly those who do not explicitly specialize in tinnitus management, may use this general term. However, even as a general practice, CBT has been shown to significantly help many patients struggling with tinnitus.

Here are links to a webinar and a podcast by Dr. Bruce Hubbard, a leading CBT and tinnitus specialist, on how CBT can help those with tinnitus.

Podcast:

Click here to listen.

Webinar:

Here is a wonderful webinar by Dr. Bruce Hubbard, Director of the Cognitive Health Group on CBT and how it can help those with tinnitus.

Mindfulness-Based Stress Reduction (MBSR)

A therapy that emphasizes “mindfulness” — an acute and non-judgemental awareness of one’s physical sensations, sensory perceptions, emotional reactions and cognitive processes. Rather than struggling (often in vain) to ignore tinnitus, MBSR teaches patients to wholly accept, embrace, and control their experience. In doing so, patients put themselves in a better position to manage their condition. It can also addresses negative feelings of anger and apathy that so often accompany tinnitus.

Acceptance and Commitment Therapy (ACT)

Like other mindful-based approaches, ACT emphasizes the need to reduce experiential avoidance of tinnitus. Patients are taught to fully experience thoughts, perceptions, and emotions in a direct, non-judgemental way. By fully accepting even negative thoughts and feelings, patients can find greater control over those reactions.

Tinnitus Activities Treatment (TAT)

A variation of CBT that focuses specifically on tinnitus management. TAT follows an incremental learning-based approach to explore four impact areas of tinnitus: thoughts and emotions, hearing and communication, sleep, and concentration. The process also generally uses low-level supplemental sound therapy for masking purposes.

Tinnitus Retraining Therapy (TRT)

A treatment regimen that combines the use of traditional CBT counseling with supplemental sound masking to habituate patients to tinnitus. The counseling component aims to demystify tinnitus and help patients reclassify tinnitus as an emotionally neutral signal. Constant low-level broadband sound is used to habituate the patient to tinnitus.

University of Iowa's Tinnitus Activities Treatment Materials

Attached below is a PowerPoint presentation of the University of Iowa's Tinnitus Activities Treatment (TAT).

Iowa's Tinnitus Activities Treatment Summary.pptx

Also, here is an interview from Spring 2018 about TAT from a clinician's perspective with Shelley Witt, AuD, a research audiologist in the Department of Otolaryngology — Head and Neck Surgery at the University of Iowa. Witt has treated thousands of patients using TAT.

Witt on TAT.pdf

For more information on using TAT with patients, contact Rich Tyler, PhD, at the University of Iowa via email: rich-tyler@uiowa.edu.

Progressive Tinnitus Management (PTM)

Developed by the U.S. Veterans Administration’s National Center for Rehabilitative Audio Research, PTM is an incremental approach to tinnitus treatment that involves comprehensive patient education, behavioral therapy, and when appropriate, supplemental sound therapy. To access the FREE digital version of the Progressive Tinnitus Management workbook and other materials, click here.

Considerations

Multidisciplinary Healthcare: Behavioral therapies for tinnitus typically require patients to see a behavioral health specialist in addition to a hearing health professional. It may also require coordinating care across multiple doctors, increasing the complexity and cost of treatment.

Time and Effort: Behavioral therapies also tend to involve multiple clinical sessions over the course of several months to several years, depending on the patient. Results are cumulative, and successful treatment often requires the full completion of therapy sessions.

Commitment: All tinnitus management programs require that the patient embraces the treatment protocol with an open mind and positive expectations. This may be particularly true for behavioral treatments that rely heavily on active and transparent patient involvement.

References

Cima, R., Andersson, G., Schmidt, CJ, and Henry, J. (2014) “Cognitive-Behavioral Treatments for Tinnitus: A Review of the Literature.” Journal of the American Academy of Audiology, 25: 29-61.

Gans, J. (2014) “Mindfulness: Changing the Brain to Change our Perception of Tinnitus.” Tinnitus Today, 39,1: 24-25.

Jastreboff, P. and Jastreboff, M. (2000) “Tinnitus Retraining Therapy: An Update.” Hearing Review, Available at: http://www.audiologyonline.com/articles/tinnitus-retraining-therapy-an-update-1286  (Accessed March 11, 2015.)

Martinez-Devesa, P., Perera, R., Theodoulou, M. and Waddell, A.. (2010)  “Cognitive Behavioural Therapy for Tinnitus.” Cochrane Database of Systematic Reviews, Issue 9. Art. No.: CD005233. DOI: 10.1002/14651858.CD005233.pub3.

Robinson, S. (2005) “Cognitive Behavioral Therapy - The Basics.” Tinnitus Today, 30,3: 11-12.

Tyler, R.S., Gogel, S.A.. and Gehringer, A.K.. (2007) “Tinnitus Activities Treatment.” Progress in Brain Research,166:425-34.

 

 

In some cases, tinnitus is caused by physiological functions or disorders within the body. In these less-common situations, addressing the baseline physical cause can eliminate or drastically reduce tinnitus symptoms.

In a vast majority of cases, tinnitus is caused by hearing loss and is a phantom auditory sensation generated by the brain in response to missing acoustic stimulation. However, tinnitus symptoms can also be generated by physical dysfunctions elsewhere in the body.

These less common cases are sometimes referred to as peripheral tinnitus — signifying that the cause is on the periphery of the nervous system, as opposed to being “centralized” in the brain. In cases of peripheral tinnitus, addressing the underlying physiological problem(s) may also treat the tinnitus.

It is important to note that these causes (and potential treatments) apply to only a very small percentage of total tinnitus cases. A qualified healthcare professional can typically diagnose and provide treatment options for the cases below.

TMJ Dysfunctions

When tinnitus is caused by a jaw joint (temporomandibular joint, or TMJ) dysfunction, dental treatment or bite realignment may relieve symptoms. A dental health professional can diagnose and fix relieve this problem.

Obstructions in the Ear

Tinnitus can be sometimes be caused by excessive earwax, a loose hair, or another object in contact with the ear drum.  Removal of the object by a qualified health professional may alleviate symptoms.

Head and Neck Injuries

Severe injury to the head or neck can cause nerve, blood flow and muscle issues that result in somatic tinnitus. Treating the underlying physical trauma via drug therapy, osteopathy, physical therapy, or chiropracty, may, in turn, remediate the tinnitus symptoms. In extreme cases, surgical practices, such as a neurectomy or microvascular decompression, may be necessary. Patients with these injuries should consult their physician to determine the best course of treatment.

Ototoxic Reactions

When tinnitus is a symptom of an ototoxic medication, a change in prescriptions or drug schedule may provide relief. Most ototoxic drugs cause only temporary acute tinnitus symptoms, which go away once the medication is fully metabolized by the body.

If you are worried about tinnitus as a side effect of your medications, please consult your subscribing physician or pharmacist. You should not stop taking any medication without first consulting with your healthcare provider. The risks of stopping a medication may far exceed any potential benefit.

The search for new tinnitus treatments and potential cures is ongoing. Here are some of the cutting-edge therapies currently in development — but which have not yet been fully validated for effective clinical use.

Research labs around the world are exploring new ways to control — and hopefully cure — tinnitus. Below, ATA has itemized some of the more promising prospective treatments for tinnitus.  Please note: these treatments are experimental and are generally not available for patients outside of controlled clinical research trials.

Why are these treatments described as “experimental?”  Most of the prospective therapies summarized below have yielded some promising preliminary outcomes data. Some have even made big, splashy headlines in the news, advertising sensational benefits. However all of these treatments are decidedly still in development. Simply put, more data is needed to validate the safety and efficacy of these treatments. This is particularly true of procedures that require invasive surgery, which may carry significant health risks that outweigh any potential benefits.

While ATA supports the ongoing development of these promising treatments, we urge patients to first try existing treatment options for tinnitus rather than wait for these options to reach the healthcare market.

Repetitive Transcranial Magnetic Stimulation (rTMS)

Strong electromagnetic stimulation is known to reduce neural activity. Because tinnitus is believed to be a function of hyperactivity in the brain’s neural cortex, many researchers believe that such stimulation can reduce the perception and severity of tinnitus. Repetitive Transcranial Magnetic Stimulation uses a powerful, noninvasive magnetic coil, carefully positioned adjacent to the the patient’s head, to deliver electromagnetic pulses into the underlying brain tissue.

Preliminary research data on rTMS has yielded mixed results, especially when rTMS patients are compared to patients in a placebo test group. To improve the clinical efficacy of rTMS, researchers need to further optimize treatment protocols, such as ideal coil placement, stimulation frequency, stimulation intensity, and the frequency of patient treatments.

Transcranial Direct Current Stimulation (tDCS)

Transcranial Direct Current Stimulation is another form of non-invasive electromagnetic treatment, which researchers hope will minimize the neural hyperactivity underlying tinnitus. Patients wear a series of electrodes on their scalp, which transmit electromagnetic pulses through the skull into the underlying brain tissue. The amount of electrical stimulation varies, depending on the neural excitability beneath each electrode.

Research on tDCS has been promising. Some studies show up to 40% of patients receive some benefit from the treatment. However, more large randomized clinical trials are needed before the full benefit of this procedure is fully validated.

Deep Brain Stimulation (DBS)

Deep Brain Stimulation is already an accepted clinical procedure for patients with Parkinson’s Disease, tremors, and other chronic medical conditions.  It is based on the concept of stimulating the brain with electromagnetic energy. However, unlike rTMS and tDCS, DBS is an invasive procedure, involving surgical implantation of electrodes directly into the brain.

Much of the data on DBS’s efficacy come from subjects who primarily received the treatment for another condition (such as Parkinson’s), but who reported a reduction of tinnitus as a peripheral benefit. Before DBS can be considered an appropriate treatment solely for tinnitus, researchers must better identify optimal target areas in the brain for stimulation.

Brain Surface Implants

Some scientists are experimenting with the use of brain surface implants — electrodes surgically positioned on the exterior of the brain.  Like other brain stimulation techniques, there is some promising preliminary evidence on brain surface implants, but further research is needed to identify ideal electrode placement on the brain. Moreover, this approach is complicated by the significant risks associated with neural surgery.

Vagus Nerve Stimulation (VNS)

The vagus nerve runs through the neck, connecting the brain to the heart and digestive system. The use of an implanted electrode to apply electrical stimulation on the vagus nerve has already been shown effective in the management of epilepsy, and depression. Some researchers believe that the same practice may assist patients with tinnitus.

Research on the impact of VNS on tinnitus is mixed, with much of the scientific output coming from private companies attempting to develop commercial VNS products. Like other in-body devices, VNS carries risks associated with surgical implantation.

References

Folmer, R.L., Theodoroff, S.M., Martin, W.H., Shi, Y. (2014) “Experimental, Controversial and Futuristic Treatments for Chronic Tinnitus.” Journal of the American Academy of Audiology, 25:106-125.