Tinnitus alone is rarely a sign of stroke; the ear symptom that can be one is sudden hearing loss, especially with severe vertigo that does not settle, which can herald a stroke at the back of the brain.
Ringing by itself seldom means a stroke, but a sudden drop in hearing with spinning vertigo is not something to wait out as an ear infection. Is tinnitus a sign of something serious? also covers tumours and multiple sclerosis.
If you are worried about a stroke now
Stop reading and call your local emergency number: 999 in the UK, 911 in the US.
The US Centers for Disease Control and Prevention (CDC) teaches the signs as BE FAST:
- B, balance loss: feeling off-balance or dizzy
- E, eye changes: trouble seeing normally
- F, face: one side of the face droops when the person smiles
- A, arms: one arm drifts downward when both are raised
- S, speech: slurred or strange speech
- T, time: call emergency services right away, and note when the symptoms first appeared
The NHS uses the shorter FAST, lists one-sided numbness, lost vision, dizziness or falling over and a severe headache among other symptoms, and says to call 999 for stroke signs in the last 24 hours even if they have stopped. Neither list mentions hearing or tinnitus.
Is tinnitus on its own a sign of stroke?
The large studies that looked for a link found little:
- In a UK Biobank analysis of 140,146 people, tinnitus was linked with small increases in heart attack and death from any cause, but had no significant association with stroke.
- The Tromsø Study, a Norwegian survey of 17,288 adults, found no significant association between tinnitus and a history of stroke, and only weak links with high blood pressure and heart attack.
- The exception, a Taiwanese insurance-records study of 3,474 adults aged 20 to 45 with ischaemic cerebrovascular disease and 17,370 controls, found tinnitus more common in the stroke group (adjusted odds ratio 1.66). Its authors ask for further investigation, and the far larger UK Biobank cohort, which followed people forward in time, found no significant link.
Anatomy fits this picture. A 2000 review notes that hearing disturbances are much less frequent in stroke than balance symptoms: much of the hearing pathway has more than one blood supply, and above the brainstem's first hearing relay each ear is represented on both sides of the brain, so gross hearing loss from damage there needs both sides hit.
Why a stroke can reach the ear
The inner ear draws its blood from the vertebrobasilar system, the arteries at the back of the neck and brain, and a 2024 review describes the labyrinthine artery as its only end artery, with no second vessel to take over. The US National Institute on Deafness and Other Communication Disorders (NIDCD) lists blood circulation problems among the possible causes of sudden deafness.
The strokes most tied to this are in the territory of the anterior inferior cerebellar artery (AICA), which supplies part of the brainstem and cerebellum:
- In a 2002 series of 12 consecutive people with AICA-territory strokes confirmed on MRI, 11 had sensorineural hearing loss, and testing placed it mostly in the cochlea, pointing to the inner ear losing its blood supply.
- A 2009 series of 82 consecutive AICA strokes found prolonged vertigo in 80 of them (98%). The commonest pattern was combined loss of hearing and balance function, in 49 people (60%). The authors note that, unlike a viral cause, a vascular cause usually takes out hearing and balance together.
In that series of 82, only one person had the ear symptoms with no other neurological symptom or sign. AICA strokes typically also bring flickering eye movements, facial weakness or unsteady walking.
The warning that can come before the stroke
The harder case is when the ear goes first. Several Korean series describe it:
- In the 2002 series, 4 of the 12 had vertigo, sudden hearing loss or tinnitus as an isolated symptom between 1 day and 2 months before the stroke.
- In the 2009 series, 13 of the 82 had brief episodes of vertigo or hearing disturbance in the month before.
- Of 54 consecutive AICA strokes in one registry, 4 (7.4%) began as vertigo and hearing loss that looked like acute labyrinthitis, with a normal MRI at the time, even on the diffusion sequence that shows fresh strokes. All four later developed further neurological problems, and repeat scans showed the infarcts.
- Of 447 people with posterior-circulation strokes, 12% had brief dizziness or vertigo in the previous 3 months, a third in the final week.
A 2012 review draws the practical conclusion: sudden hearing loss with prolonged vertigo may herald an AICA stroke, especially in people with narrowing or blockage of the basilar artery, even when other brain signs are absent and the MRI is normal.
Most of these series are small, and all of them start from people who had already had a stroke, so they show the warning exists but cannot say how often vertigo with hearing loss turns out to be one.
How doctors tell an inner-ear problem from a stroke
Continuous vertigo with flickering eye movements (nystagmus), nausea or vomiting, intolerance of head movement and unsteady walking is called the acute vestibular syndrome. It is often vestibular neuritis, an inflamed balance nerve, but some is stroke: a 2013 US study cites estimates that 4% to 6% of US emergency visits for dizziness and vertigo have a cerebrovascular cause.
The bedside test built for this is HINTS: three eye-movement checks, the Head Impulse test, the Nystagmus pattern and a Test of Skew for vertical eye misalignment.
- In the 2009 study that introduced it, in 101 high-risk patients, any one of the three central signs was 100% sensitive and 96% specific for stroke. Sensitivity is the share of strokes the test flags; specificity, the share of non-strokes it correctly clears.
- In a 2013 study of 190 patients, HINTS detected stroke with a sensitivity of 96.5% and a specificity of 84.4%.
HINTS plus adds one more question: is there new hearing loss in one ear? That matters most for AICA strokes. In HINTS, a normal head impulse test points towards stroke and an abnormal one usually points to the ear. AICA strokes can break the rule, because the inner ear itself can lose its blood supply and the head impulse test comes out looking like ear disease.
- A 2026 systematic review of 11 studies and 770 patients found HINTS alone had a sensitivity of 92.7%; adding hearing loss raised it to 95.7%. For AICA strokes specifically, sensitivity rose from 73.3% to 91.1%. Specificity fell from 91.1% to 80.7%, which the authors attribute largely to how patients were selected. Two of its authors led the 2009 study that introduced HINTS.
- A 2026 meta-analysis by a group not involved in developing HINTS found similar sensitivities, 0.97 for HINTS and 0.99 for HINTS plus, though only 265 patients were tested with the latter.
- A Swiss emergency department study of 71 patients found new hearing loss on testing in 12.7%, and 55% of them had not noticed it. Formal audiometry did not improve accuracy, but complete hearing loss was a red flag: three in four with one had a cause in the brain.
The limit is who performs it. The 2023 GRACE-3 guideline from the Society for Academic Emergency Medicine recommends HINTS for clinicians trained in its use, with a finger-rub hearing check to help exclude stroke, and states that HINTS is inaccurate in routine use by emergency clinicians without special training, and that most have not been trained in it. It is not a self-test, and it is for continuous vertigo, not brief dizziness on rolling over in bed. Vertigo, dizziness and tinnitus covers the wider range of causes.
Why a normal scan early on does not settle it
- CT is the wrong test for this question. GRACE-3 recommends against brain CT for the acute vestibular syndrome, and the 2019 US sudden hearing loss guideline strongly recommends against routine head CT at the first assessment.
- Early MRI misses some strokes. The first diffusion MRI was falsely negative in 12% of strokes in the 2009 HINTS study and in 15 of 105 infarctions (14.3%) in the 2013 study, nearly all scanned within 48 hours of onset. Later scans confirmed them.
- GRACE-3 uses MRI to confirm, recommending it where the HINTS examination looks central or is equivocal.
The 2019 guideline also asks clinicians to look for focal neurological findings in anyone with sudden hearing loss; sudden sensorineural hearing loss covers the rest of that assessment.
Does sudden hearing loss raise the risk of a later stroke?
A Taiwanese cohort published in Stroke first asked this, and later studies broadly agree, with smaller effects:
- Taiwan, 2008: of 1,423 people hospitalised for sudden hearing loss, 12.7% had a stroke within 5 years, against 7.8% of 5,692 appendectomy patients standing in for the general population; the adjusted hazard was 1.64 times higher.
- Korea, 2018: ischaemic stroke was diagnosed in 4.2% of 4,944 people with sudden hearing loss against 3.5% of 19,776 matched controls, an adjusted hazard ratio of 1.22, and 1.40 in men aged 50 and over. Bleeding strokes were not increased.
- With vertigo, 2018: in 218,656 Taiwanese patients followed for at least three years, stroke occurred in 5.5% of those with sudden hearing loss plus vertigo, 3.0% with sudden hearing loss alone and 3.9% with vertigo alone.
- Pooled: a 2021 meta-analysis of three studies and 6,521 patients found a 1.42-fold risk of stroke after sudden hearing loss, and in one study's subgroup the extra risk appeared only over age 50. A broader 2021 meta-analysis of eight cohort studies of hearing loss found an adjusted hazard ratio of 1.44 in its sudden hearing loss subgroup.
In absolute terms, about 96 in 100 people with sudden hearing loss in the Korean cohort had no ischaemic stroke recorded. All of these are observational, mostly from insurance records, and a 2024 review notes that many studies link sudden hearing loss with atherosclerosis, diabetes, high blood pressure and abnormal blood fats, so shared risk factors may explain part of the link. The authors of the three-study meta-analysis say more studies are needed to show whether these patients benefit from cardiovascular risk assessment. Tinnitus and blood pressure covers one of those risk factors.
Pulsing tinnitus is a separate question
Tinnitus that beats in time with your pulse has its own causes, one of them a tear in the wall of a neck artery, which can lead to a stroke. A 2022 review lists pulsatile tinnitus, head and neck pain and Horner syndrome, mainly a drooping eyelid with a small pupil, among a tear's local symptoms, and says a suspected tear needs emergency assessment with scans of the head and neck arteries. In a European study of 778 people with such a tear, 63 (8.1%) reported pulsatile tinnitus. Pulsatile tinnitus and cervical artery dissection and tinnitus cover both in full.
What to do, by situation
- Call your emergency number now for any BE FAST sign, for sudden hearing loss with severe vertigo or imbalance that does not settle, for tinnitus or hearing loss with any new neurological symptom, for new pulsing tinnitus with neck pain, a new headache or a drooping eyelid, or for stroke signs in the last 24 hours that have since gone.
- Be seen the same day for hearing that drops all at once or over a few days, even without dizziness. NIDCD advises treating sudden deafness as a medical emergency and seeing a doctor immediately. Say "sudden hearing loss" and when it started.
- Book a routine appointment for tinnitus that came on gradually, with no hearing drop, vertigo or neurological symptoms.
The when to see a doctor checklist walks through these patterns one question at a time, and how tinnitus is diagnosed explains what a first assessment involves.