NICE's tinnitus guideline, NG155, asks clinicians to offer everyone with tinnitus a hearing assessment, offer amplification where hearing loss affects communication, consider stepped psychological therapy for distress, not offer betahistine, and refer a short list of warning signs urgently.
The UK's National Institute for Health and Care Excellence published Tinnitus: assessment and management on 11 March 2020. It covers primary, community and secondary care, and applies to children and young people as well as adults unless a recommendation says otherwise. Its context section notes that UK services varied in access and support and lacked a standard approach.
How to read NICE's wording
NICE signals certainty through its verbs. Where there is clear and strong evidence of benefit it says offer; where the benefit is less certain it says consider. The guideline also uses "do not offer". A 2023 systematic review of 10 tinnitus guidelines found that NICE rated the quality of evidence using GRADE but attached no explicit grade to individual recommendations, so the verbs carry the strength.
The guideline's rationale is candid about what sits beneath the verbs. For eight of the 16 topics it covers, the committee records that no evidence was identified: every referral timing, all the questionnaires, the hearing tests, pitch and loudness matching, and both scanning pathways. Those recommendations rest on the committee's clinical judgement and, for referrals, on other NICE guidelines. The offer of a hearing assessment to everyone is firm wording with no clinical evidence behind it; the committee made it because some people with tinnitus do not realise they also have hearing loss.
What it asks for at the first appointment
Two ideas run through the guideline. The first is tinnitus support: a two-way conversation in which the clinician learns what the tinnitus is doing to someone's life and what they want, and a management plan is agreed together and revised as needed. It replaces "tinnitus counselling", a term the committee found used for anything from brief reassurance to a long session about someone's worries.
The second is what people should hear the first time they raise tinnitus with any healthcare professional. NICE asks clinicians to reassure them that:
- tinnitus is common
- it may resolve by itself
- it is commonly associated with hearing loss, but not commonly with other underlying physical problems
- a variety of management strategies help many people live well with it
The committee's reasoning is pointed: being told that nothing can be done and you have to live with it may worsen how a person perceives their tinnitus and affect their mental wellbeing. If that is what you have heard, when your doctor dismisses your tinnitus covers how to get a more useful appointment. NICE also wants people told what can make tinnitus worse, such as stress or loud noise, and about safe listening, self-help and support groups.
When it says to refer, and how fast
NICE sorts referrals by urgency:
- Immediately, to a crisis mental health team: tinnitus with a high risk of suicide.
- Immediately: tinnitus with sudden significant neurological symptoms such as facial weakness, acute vertigo or other balance symptoms that are not under control, or suspected stroke. NICE defines "immediately" as seen by the specialist service within a few hours, or sooner if necessary.
If either of these describes you now, contact emergency services or a crisis line rather than waiting for an appointment. The other tiers:
- Within 24 hours: tinnitus with hearing loss that developed over 3 days or less, within the past 30 days. Sudden hearing loss explains why the days matter.
- Within 2 weeks: distress affecting mental wellbeing, such as distress that stops someone carrying out their usual daily activities, that continues after first-line support; or hearing loss that came on suddenly more than 30 days ago, or worsened rapidly over 4 to 90 days.
- Refer: tinnitus that still bothers someone after first-line support, persistent objective tinnitus (a sound an examiner can detect), or tinnitus with one-sided or asymmetric hearing loss.
- Consider referring: persistent pulsatile tinnitus or persistent one-sided tinnitus.
NICE deliberately names no destination, because tinnitus pathways vary across the UK; audiology and ENT services are the common ones. The when to seek care checklist walks through the warning signs.
Tests: what to expect, and what NICE says to skip
- A hearing assessment, offered to everyone with tinnitus.
- Tympanometry, considered when a middle-ear or Eustachian tube problem is suspected.
- Not acoustic reflex or loudness discomfort testing. The committee, drawing on its members' experience, judged these can be unnecessary, unpleasant and potentially harmful: they may make tinnitus worse, and their results would not change management. Otoacoustic emissions tests are for when other symptoms accompany the tinnitus.
- Not pitch and loudness matching. The committee's concern is that these tests may add distress and encourage people to focus on the sound, which can work against habituation, while the result does not change routine management. NICE's reasoning would apply equally to home versions, including the site's own frequency test: a matched pitch will not change what you are offered.
- Questionnaires: consider the Tinnitus Functional Index for adults, chosen because it gives the broadest assessment and was designed to measure change; ask about sleep and consider the Insomnia Severity Index; consider the Tinnitus Questionnaire or mini-TQ for psychological effects. How tinnitus is measured explains what the scores mean.
- Scans: offer MRI for non-pulsatile tinnitus with neurological, ear or head and neck signs; consider it for one-sided or asymmetric tinnitus without them; do not scan symmetrical non-pulsatile tinnitus with no other signs, because the incidence of underlying disease is very low; and offer imaging to everyone with pulsatile tinnitus. Whether you need a scan covers that decision.
Treatments: offer, consider, do not offer, and not yet
Hearing aids and other amplification. Offer them when hearing loss affects the ability to communicate; consider them when there is hearing loss without communication difficulty; do not offer them without hearing loss, because amplified sound may itself cause hearing loss. The 2023 review notes that NICE made this recommendation despite a lack of evidence on effectiveness for tinnitus. Hearing aids for tinnitus covers the trials.
Psychological therapy. For adults whose tinnitus still affects their emotional and social wellbeing and daily activities after support, NICE says to consider a stepped approach, moving on if a step does not help or is declined:
- digital tinnitus-related CBT provided by psychologists
- a group-based intervention: mindfulness-based cognitive therapy, ACT or CBT
- individual tinnitus-related CBT delivered by psychologists
The committee found evidence that CBT, mindfulness-based CBT and acceptance and commitment therapy (ACT) are effective for tinnitus-related distress, but the cost-effectiveness of each was uncertain; the order follows economic analyses suggesting it is cheaper to start with digital or group therapy. In 2020, the committee noted, digital CBT for tinnitus was available only in research. The recommendation covers adults, because no evidence was found on psychological therapies for children and young people. For scale, a Cochrane review published two months before the guideline estimated that CBT lowered Tinnitus Handicap Inventory scores by 10.91 points against a waiting list, on low-certainty evidence. CBT for tinnitus, internet-based CBT and mindfulness and ACT cover the trials.
Betahistine. Do not offer it to treat tinnitus. It is licensed for Ménière's disease, not for tinnitus alone, and the evidence suggested it does not improve tinnitus, with some evidence of adverse effects. Betahistine for tinnitus sets out that evidence.
No recommendation, in three areas:
- Sound therapy, because many types are in use and the evidence was insufficient for any one of them.
- Combinations, including tinnitus retraining therapy. The committee said the original TRT protocol does not let people take an active part in shaping their plan, that TRT is used in modified forms, and that the trials it found did not reflect TRT as delivered.
- Neuromodulation, such as TMS, because approaches vary greatly and robust evidence was insufficient.
Not addressed at all: ginkgo, zinc and other supplements, antidepressants and anticonvulsants. Other guidelines cover them, and drugs for tinnitus sets out the trials.
"No recommendation" is not "no"
In all three areas NICE's reason was limited or unrepresentative evidence, not evidence that the treatments fail. It made 12 recommendations for research in all, covering these gaps and several other questions. The five marked as key ask about CBT delivered by trained professionals other than psychologists, such as audiologists; sound therapy combined with tinnitus support; how to assess tinnitus in general practice; neuromodulation in adults; and psychological therapies for children and young people.
A 2023 opinion paper by Langguth and colleagues calls NICE's probably the most innovation-friendly tinnitus guideline, because where evidence is inconclusive it asks for research rather than recommending against. The same paper quotes the committee explaining that, because neuromodulation was not offered for tinnitus on the NHS, any recommendation would have had a large impact on practice, so the evidence was not enough. The authors read that as a higher bar for new treatments than for established ones. Several of them declare consulting, advisory or research ties to neuromodulation companies, while stating that none of that funding relates to the paper.
How it compares with other guidelines
The 2023 systematic review compared 10 guidelines published between 2011 and 2021, NICE among them. Counselling and CBT were the only treatments recommended by every guideline that addressed them; tinnitus retraining therapy, sound therapy, hearing aids and cochlear implants were not recommended unanimously. NICE's was the only one to report resource implications.
Set against the 2014 US guideline from the American Academy of Otolaryngology–Head and Neck Surgery (AAO-HNS) and the 2019 multidisciplinary European guideline:
- CBT. AAO-HNS recommends it; the European guideline gives it its only strong recommendation for a treatment; NICE says consider, in steps.
- Hearing aids. AAO-HNS recommends a hearing aid evaluation when hearing loss is documented. The European guideline gives a weak recommendation for people with hearing loss and says not to offer them without it, the same line NICE draws.
- Sound therapy. An option for AAO-HNS, no recommendation in the European guideline, and a research question for NICE.
- TMS. AAO-HNS and the European guideline both recommend against it; NICE asked for research.
- Drugs and supplements. AAO-HNS recommends against antidepressants, anticonvulsants, anxiolytics, intratympanic medications and supplements; the European guideline recommends weakly against drugs and against supplements. NICE addresses betahistine only.
- Scans. AAO-HNS strongly recommends against imaging for tinnitus that is not one-sided or pulsatile and comes without focal neurological signs or asymmetric hearing loss, which matches NICE's advice.
The 2024 VA/DoD guideline came later, with 25 recommendations, and has its own walkthrough. For the European, German, Japanese and Korean guidelines alongside these, see seven tinnitus guidelines compared. The treatment comparison shows where the US guidelines land on each option.
What has changed since 2020
NICE's history page for NG155 lists nothing after its publication date, and the guideline notes that its recommendations were developed before the COVID-19 pandemic.
Some of its open questions have been studied since. A 2022 US trial randomised 158 adults to audiologist-guided internet CBT or weekly monitoring, and CBT reduced distress on the Tinnitus Functional Index more (effect size 0.46), with the gain holding over two months of follow-up. It compared CBT with monitoring rather than with psychologist-delivered CBT, and questionnaire completion had fallen to 42% by the final assessment, so it supports the approach without settling NICE's question.
Using it at an appointment
- Ask for a hearing assessment if you have not had one; NICE says to offer it to everyone with tinnitus.
- Ask for a Tinnitus Functional Index score as a baseline, so anything you try can be judged against it.
- If you are offered betahistine for tinnitus without Ménière's disease, it is reasonable to ask why.
The guideline tells clinicians what to offer; it does not decide for you. How tinnitus is diagnosed describes what a full assessment involves.