Which evidence-based therapies should be considered first-line for chronic tinnitus?
Executive summary
Clinical guidelines and multiple systematic reviews converge on a short list of first‑line, evidence‑based approaches for chronic subjective tinnitus: psychological interventions—chiefly cognitive behavioral therapy (CBT)—and pragmatic audiological care (hearing aids or counseling) tailored to hearing loss, with combined sound‑based and behavioral programs often used in practice; many technological and pharmacologic interventions remain investigational or show mixed results [1] [2] [3]. Emerging neuromodulation and device therapies show promise but are not yet established first‑line options for all patients [4] [5].
1. Cognitive behavioral therapy: the guideline‑backed frontline therapy
Cognitive behavioral therapy is the only intervention that guideline authors consistently give strong recommendations for when the clinical goal is to reduce tinnitus‑related distress rather than to abolish the phantom sound, with multiple meta‑analyses and systematic reviews demonstrating reductions in tinnitus distress and negative cognitions about tinnitus [1] [2] [6]. CBT’s benefit is concentrated on emotional and cognitive reactions to tinnitus rather than reliably reducing sound loudness, and long‑term outcome data remain limited in some reviews, but its evidence base is the clearest among non‑invasive therapies [1] [2].
2. Audiological care and hearing‑loss correction: treat the ears to help the brain
When tinnitus coexists with hearing loss, fitting appropriately tuned hearing aids or providing audiological counseling is a primary, evidence‑based step because restoring audibility can reduce tinnitus intrusiveness and improve coping; major reviews and patient‑facing guidance identify hearing aids and counseling among the most effective, accessible interventions for many patients [7] [8] [3]. Randomized trial evidence specifically isolating hearing aids for tinnitus is limited and heterogeneous, and outcomes depend on fitting procedures and individual hearing profiles, so audiological care must be individualized [8].
3. Sound therapy and tinnitus retraining approaches: useful adjuncts but evidence is mixed
Broad categories such as sound masking, tinnitus retraining therapy (TRT), and sound generators are commonly offered and can help in habituation or to reduce attention to tinnitus, but systematic reviews and a Cochrane analysis find the quality of evidence weak or inconsistent, with some randomized controlled trials showing no clear superiority over counseling or usual care [1] [2] [8]. Combining acoustic approaches with CBT shows promise in network analyses and may be more effective than either alone for certain outcomes, but heterogeneity in methods limits firm, universal recommendations [9] [3].
4. Targeted physical therapies for somatosensory tinnitus: a niche, evidence‑informed option
For patients whose tinnitus is influenced by orofacial or neck problems—so‑called somatosensory tinnitus—physiotherapy, manual therapy, or targeted orofacial treatment have produced promising results in controlled studies and guideline summaries and warrant consideration as a first‑line option in that subgroup [10] [11]. The benefit appears mediated by reduction in temporomandibular or cervical pain, so careful diagnostic phenotyping is essential before pursuing manual therapies [11].
5. Neuromodulation, devices and pharmacotherapy: promising but not universal first‑line
Bimodal neuromodulation (audio plus somatosensory stimulation) and other non‑invasive brain stimulation techniques have advanced rapidly and are described as “promising” by patient organizations and early studies, with some devices receiving regulatory approval and media attention; however, these remain emerging options whose patient selection, durability, and comparative effectiveness against CBT/audiological care are not yet settled [4] [5] [12]. Pharmacologic and many complementary therapies lack robust evidence and are not routinely recommended by contemporary guidelines [3] [11].
6. How to choose first‑line care: match evidence to the patient, not the technology
Consensus reviews and an umbrella review emphasize a stepwise, individualized approach: start with validated psychological support (CBT) for distress and with audiological assessment and hearing‑loss correction where indicated, add sound or retraining therapies and somatosensory approaches when phenotypes suggest benefit, and reserve neuromodulation or experimental drugs for refractory cases or research settings; access, therapist expertise, and patient preference shape what becomes “first‑line” in practice [3] [1] [7]. It is important to note gaps in long‑term outcome data and the heterogeneity of trials, and that commercial messaging for new devices may overstate generalizability beyond studied populations [13] [5].