Tinnitus treatments with real evidence behind them

Cognitive behavioral therapy (CBT) has the best evidence for making tinnitus less bothersome. If you also have hearing loss, a hearing aid evaluation is the next step, and sound therapy is a reasonable add-on. The tinnitus guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation (AAO-HNSF) advises clinicians not to routinely prescribe drugs or transcranial magnetic stimulation to treat tinnitus itself, and not to recommend dietary supplements ^[1][2].

No pill or procedure reliably switches the sound off. NIDCD says there are no medications specifically for treating tinnitus ^[3]. What the evidence supports are approaches that shrink how much the sound intrudes on your sleep, focus and mood. Surveys estimate that 10% to 25% of adults have tinnitus ^[3], so you are far from alone.

What the guidelines recommend, at a glance

The AAO-HNSF published its tinnitus guideline in 2014 for adults with persistent, bothersome tinnitus ^[1]. It is still the academy's current version; an update is listed as in development ^[9]. The 2024 VA/DoD tinnitus guideline, which reviewed evidence through April 2023, reached similar conclusions on most points ^[8].

Treatment	What the evidence says	AAO-HNSF 2014	VA/DoD 2024
Cognitive behavioral therapy	28 trials, 2,733 adults: about 11 points better on the 100-point Tinnitus Handicap Inventory than no treatment (low certainty) [4]	Recommended [2]	Suggested [8]
Hearing aids, if you have hearing loss	People improved in small trials, but none compared hearing aids with no treatment (low certainty) [5]	Recommends a hearing aid evaluation [2]	Suggested [8]
Sound therapy (sound generators, combination devices)	No device beat another; no evidence it beats a control (low certainty) [5]	Option [2]	Suggested for self-care [8]
Education and counseling	Foundation of every plan	Recommended [2]	Suggested [8]
Lenire bimodal device	FDA De Novo authorization in 2023; sponsor-funded trials with no sham device [6][7]	Not addressed (the guideline predates it)	Listed as an available device, with no recommendation [8]
Antidepressants, anticonvulsants, anti-anxiety drugs, ear injections	Not supported as tinnitus treatments	Recommends against routine use [2]	Suggests against [8]
Ginkgo, melatonin, zinc, other supplements	Not shown to help	Recommends against [2]	Suggests against [8]
Transcranial magnetic stimulation (TMS)	Not supported for routine use	Recommends against routine use [2]	Insufficient evidence [8]
Acupuncture	Unclear	No recommendation [2]	Insufficient evidence [8]

Start with a proper check

The guideline's first steps are a targeted history and physical exam, then a prompt, full hearing test if your tinnitus is in one ear, has lasted six months or longer, or comes with hearing trouble ^[2]. Your clinician should also sort out whether the tinnitus bothers you and whether it is new or long-standing, because that shapes what comes next ^[2].

NIDCD suggests starting with your primary care doctor, who can check for earwax or fluid, review your medicines, and refer you to an ENT or audiologist ^[3]. Our guide to what happens at a hearing test walks through that visit.

Scans are not routine. The guideline advises against head and neck imaging for tinnitus unless you have tinnitus in one ear, pulsatile tinnitus, focal neurological signs, or uneven hearing loss between your ears ^[2].

Get seen promptly if you have:

• Tinnitus in one ear only, or hearing loss that is worse in one ear ^[2]
• A whooshing or thumping that keeps time with your heartbeat. See our guide to pulsatile tinnitus ^[2]
• Sudden hearing loss. Treat it as an emergency and read our sudden hearing loss guide
• Weakness, numbness, vision changes or other new neurological symptoms ^[2]
• Tinnitus that is wrecking your sleep or mood. The guideline's fact sheet notes depression has been reported in 48% to 60% of people with tinnitus ^[1]. If you ever have thoughts of harming yourself, call or text 988.

Cognitive behavioral therapy: the strongest evidence

CBT does not try to make the sound quieter. It works on how you think about, react to and cope with the sound. The Cochrane review's main outcome was the impact of tinnitus on quality of life, not loudness ^[4].

What the 2020 Cochrane review found ^[4]:

• 28 randomized trials with 2,733 adults who had tinnitus for at least three months
• Compared with no treatment, CBT lowered Tinnitus Handicap Inventory scores by about 10.9 points, above the 7-point change people tend to notice (low-certainty evidence)
• Compared with audiological care, the gain was about 5.7 points (moderate certainty)
• Programs ran 3 to 22 weeks, mostly in clinics or online
• Few or no side effects were reported
• No trials reported results at 6 or 12 months, so how long benefits last is unknown

The AAO-HNSF guideline rates the evidence behind its CBT recommendation at grade A, its highest level ^[2]. Ask your ENT or audiologist for a referral to a psychologist or counselor who runs a tinnitus-specific program. Online programs also exist; the Cochrane review included internet-delivered CBT ^[4].

Hearing aids and sound therapy

If a hearing test shows hearing loss, the guideline recommends a hearing aid evaluation ^[2], and the VA/DoD guideline suggests hearing aids for adults with hearing loss and tinnitus ^[8]. The aim is that hearing more of the sound around you makes the tinnitus less noticeable. Combination devices, which pair amplification with a built-in sound generator, are available from all the major hearing aid makers ^[8].

Sound therapy uses outside sound to cover, distract from, or help you get used to tinnitus. Options include tabletop or smartphone sound generators, wearable sound generators, and combination devices ^[3]. Tinnitus retraining therapy (TRT) pairs counseling with sound therapy ^[3].

The evidence is thin but not negative. A 2018 Cochrane review of 8 trials and 590 adults found people improved meaningfully with hearing aids, sound generators and combination devices alike, but no device beat another, and no trials compared them with no treatment ^[5]. The guideline lists sound therapy as an option ^[2]. A fan or a white-noise app at bedtime is a low-cost way to start.

For adults with severe hearing loss who qualify for a cochlear implant, the VA/DoD guideline suggests implantation can also help tinnitus ^[8].

Lenire: what the FDA authorized, and what we don't know yet

Lenire is a prescription device that plays sounds through headphones while a small piece in your mouth sends electrical pulses to your tongue. This pairing is called bimodal neuromodulation.

What the FDA said. On March 6, 2023, the FDA granted Lenire's De Novo request and placed it in Class II ^[6]. It is indicated to "temporarily relieve the symptoms of tinnitus" in adults 18 and older whose tinnitus is at least moderate on the Tinnitus Handicap Inventory, used at home after a prescription from a clinician experienced in tinnitus care ^[6]. A De Novo grant authorizes a new type of device with safety controls. It is not a finding that the device beats CBT or hearing aids.

What the main published trial showed. The TENT-A2 trial fitted 191 adults with one of two device settings ^[7]:

• Average Tinnitus Handicap Inventory scores fell 12.9 and 11.5 points after six weeks, and 18.5 points across 12 weeks
• The two settings performed about the same
• There was no sham (placebo) device, so some improvement may come from expectation or time
• The most common side effect was increased tinnitus (79 events in 71 people); there were no treatment-related serious adverse events
• Neuromod, the manufacturer, sponsored the trial, and several authors were employees, consultants or shareholders

The FDA's risk list for this device type includes increased tinnitus, skin or mouth irritation, pain, headache, and hearing loss from overstimulation ^[6]. The VA/DoD guideline lists Lenire among available tinnitus devices, with about an hour a day of recommended use, but says inclusion does not imply endorsement ^[8].

Fair reading: Lenire is a reasonable conversation to have if your tinnitus is still moderate or worse after the basics. Ask about total cost, the return policy, and how your progress will be measured.

What the guideline advises against

Drugs as tinnitus treatment. Clinicians should not routinely prescribe antidepressants, anticonvulsants, anti-anxiety drugs or medicines injected through the eardrum to treat persistent, bothersome tinnitus ^[2]. The VA/DoD guideline also suggests against betahistine, antiemetics, antithrombotics, intratympanic steroid injections and NMDA receptor antagonists for tinnitus ^[8]. This does not rule out treating depression, anxiety or insomnia; NIDCD notes doctors may prescribe these drugs for mood or sleep ^[3].

Supplements. The guideline says not to recommend ginkgo biloba, melatonin, zinc or other dietary supplements ^[2]. See our review of tinnitus supplements.

Magnetic stimulation and lasers. The AAO-HNSF recommends against routine TMS ^[2]. The VA/DoD calls the TMS evidence insufficient and suggests against low-level laser therapy ^[8].

A sample plan, step by step

1. See primary care or an ENT to rule out earwax, infection and medicine side effects ^[3].
2. Get a full hearing test ^[2].
3. If you have hearing loss, get a hearing aid evaluation, and ask about combination devices ^[2][8].
4. Add sound at home, especially at night ^[3].
5. If tinnitus stays bothersome, ask for CBT. The guideline treats tinnitus lasting six months or more as persistent ^[2][4].
6. Track your progress with a questionnaire such as the Tinnitus Handicap Inventory or Tinnitus Functional Index. The VA/DoD guideline suggests these for monitoring treatment ^[8].
7. Still moderately bothered? Discuss whether a device such as Lenire fits your situation ^[6].

To start, find an audiologist or ENT near you and mention tinnitus when you book.