For insomnia that comes with tinnitus, CBT for insomnia (CBT-I) has the best evidence, including a randomised trial in which over 80% improved meaningfully; sleeping pills have almost no tinnitus-specific evidence at all.
This page covers the research. For the practical side of getting to sleep tonight, such as sound in the room, volume and routine, see sleeping with tinnitus.
How common is insomnia with tinnitus?
Common, but the figure depends on who is asked and how. A 2022 meta-analysis pooled seven studies covering 3,041 people with tinnitus, using sleep-quality questionnaires such as the Pittsburgh Sleep Quality Index, and put the prevalence of poor sleep quality at 53.5% (95% CI 40.2–66.8%). The studies disagreed with each other far more than chance would explain (I² = 97.8%), so the pooled number is a rough centre rather than a precise rate.
Figures from specialist clinics can run higher. In a UK audiology clinic, 70% of 1,066 consecutive tinnitus patients reported some form of insomnia on the Insomnia Severity Index. And in comparative terms, a 2025 meta-analysis of 22 studies found tinnitus associated with insomnia at an odds ratio of 3.07, a stronger association than it found for depression or anxiety.
What predicts insomnia in tinnitus?
The consistent finding is that insomnia follows how much the tinnitus distresses someone, not how loud it is.
- Loudness works through distress. In 417 patients at a UK audiology clinic, the link between tinnitus loudness and insomnia was fully explained by depression, tinnitus handicap and annoyance. Once those were accounted for, loudness had no significant direct effect on insomnia.
- Mood and annoyance matter more than hearing. In 444 patients seen for tinnitus or hyperacusis, insomnia severity was associated with depression, tinnitus annoyance, anxiety and tinnitus handicap, which together explained 45% of the variation. Loudness, hyperacusis, hearing thresholds, age and gender were not related to insomnia. In the 1,066-patient study, hearing thresholds did not predict insomnia either.
- Distress, not duration. In 173 patients at a German tinnitus centre, emotional and cognitive distress and bodily complaints tracked insomnia severity, while age and how long someone had had tinnitus did not.
- The same habits as ordinary insomnia. A 2023 study of 180 people compared four groups. People with tinnitus-related insomnia had worse sleep-related thoughts and behaviours than people with tinnitus who slept well, and did not differ from people with insomnia and no tinnitus. The authors concluded these processes matter more than tinnitus severity.
One proposed explanation is that distressing tinnitus and insomnia share a common driver: hyperarousal, an overactive stress response. A 2013 review set out the evidence for that idea, but it remains a hypothesis. Every study above is cross-sectional, so none can say whether poor sleep worsens distress, distress worsens sleep, or both.
If low mood or anxiety are part of the picture, tinnitus and depression and tinnitus and anxiety cover them. Where lost sleep and low mood have reached thoughts of suicide, tinnitus and suicidal thoughts covers where to get help now.
CBT for insomnia: the trials in people with tinnitus
CBT-I is a structured programme aimed at the sleep problem itself. The American Academy of Sleep Medicine's 2021 guideline strongly recommends multicomponent CBT-I for chronic insomnia in adults, and more cautiously suggests some of its single parts, such as stimulus control, sleep restriction and relaxation, on their own. The same guideline suggests against sleep hygiene advice as a treatment on its own. The American College of Physicians recommends CBT-I as the first treatment for chronic insomnia in all adults (strong recommendation, moderate-quality evidence).
The tinnitus-specific evidence came in three steps.
- An uncontrolled clinic study (2019). Twenty-four adults with distressing tinnitus and poor sleep took six group sessions of CBT-I in a routine clinic, and 22 finished. Afterwards, 67% had reliably improved insomnia and 50% reliably lower tinnitus distress. With no comparison group, it could not show how much was due to the therapy.
- A randomised trial (2023). 102 people with tinnitus-related insomnia were randomised to CBT-I, audiology-based care or a sleep support group. CBT-I reduced insomnia and improved sleep efficiency more than audiology-based care, both after treatment and at six months. More than 80% in the CBT-I group reported clinically meaningful improvement, against 47% with audiology-based care and 20% in the support group. CBT-I also did more to reduce tinnitus distress.
- A meta-analysis (2021). Pooling four randomised trials of CBT-based treatment in adults with tinnitus, it found Insomnia Severity Index scores fell by 3.28 points (95% CI −4.51 to −2.05), with no sign of inconsistency between trials. Risk of bias was low except for blinding of participants, therapists and assessors.
A Swedish trial adds indirect support. In 32 people whose insomnia came with hearing impairment, 53–77% responded to CBT-I on the Insomnia Severity Index, against 0–7% on a waiting list.
The limits are real. There is one randomised trial of CBT-I built for tinnitus-related insomnia, from one research group, and the 2021 meta-analysis found blinding the weak point in the trials it pooled. The findings are consistent, though, and they agree with the general insomnia evidence behind the guidelines.
Sleep in ordinary tinnitus CBT
General CBT for tinnitus is not the same programme, but it often improves sleep too. In a UK trial, 146 adults were randomised to eight weeks of audiologist-guided internet-based CBT or weekly monitoring. Tinnitus distress, measured on the Tinnitus Functional Index, fell further with the programme, and so did insomnia, a secondary outcome, with the gains holding two months later.
The 2023 trial adds a head-to-head comparison: audiology-based care helped sleep, but CBT-I, which targets the sleep problem directly, helped more.
Sleeping pills: how thin the tinnitus evidence is
No randomised trial of zolpidem, zopiclone or the other Z-drugs as a treatment for tinnitus-related insomnia is indexed in PubMed. What is known about them comes from insomnia research in general.
- For insomnia in general, the American Academy of Sleep Medicine's 2017 guideline suggests zolpidem, eszopiclone, zaleplon, suvorexant, temazepam, triazolam, ramelteon and doxepin for specific kinds of insomnia, every one as a weak recommendation. It suggests against trazodone, diphenhydramine, melatonin, tryptophan and valerian, also weakly.
- As a second step, the American College of Physicians advises deciding with the patient whether to add medication only when CBT-I alone has not worked, after discussing the benefits, harms and costs of short-term use (weak recommendation, low-quality evidence).
- A possible link to tinnitus. A 2025 study of Taiwan's national insurance records compared 16,225 Z-drug users with 1,370,776 non-users. Over five years, users were more likely to be diagnosed with tinnitus, with an adjusted hazard ratio of 1.50 (95% CI 1.42–1.58), and the link held after propensity matching. The authors name residual confounding and misclassification as limitations. Insomnia is itself strongly associated with tinnitus, so this cannot show that the drugs cause it.
Benzodiazepines have been tested for tinnitus itself rather than for sleep. A 2015 systematic review found six trials: clonazepam looked effective in three with blinding problems, diazepam did not help in two, oxazepam helped in one, and alprazolam's results were equivocal. It concluded the evidence base is not robust and that serious side effects call for caution. The AAO-HNS guideline recommends against anxiolytics, along with antidepressants and anticonvulsants, for the routine treatment of tinnitus. Tapering matters too: a 2020 report described tinnitus starting within seven weeks of a gradual taper that halved a years-long clonazepam dose, found other published cases, and called it rare. Benzodiazepine withdrawal and tinnitus and drugs for tinnitus go further.
None of this means a short course of a sleep medicine is wrong for someone. It means the choice rests on general insomnia evidence and a conversation with a prescriber, not on tinnitus research.
Melatonin
Melatonin for tinnitus has its own page, and the short version agrees with it. In a 1998 placebo-controlled crossover trial of 30 patients, scores on the Tinnitus Handicap Inventory ended almost level on melatonin and placebo. Among patients whose tinnitus disturbed their sleep, 46.7% reported overall improvement on melatonin against 20.0% on placebo. A 2015 review of five studies found their weaknesses too serious to confirm that melatonin treats tinnitus, while noting it seems to improve tinnitus-related sleep disturbance.
The guidelines are cooler. The AAO-HNS guideline recommends against melatonin as a tinnitus treatment, and the sleep academy's 2017 guideline suggests against it for chronic insomnia in general. At most, melatonin is a low-risk thing to discuss with a doctor or pharmacist, not a substitute for CBT-I.
Sound at night
Sound at night is common practical advice, but it has barely been tested as a sleep treatment. In a 2017 randomised trial, 60 people used one of three sound devices during sleep. All three groups improved on tinnitus measures, and the two devices under test did somewhat better than a bedside sound generator on the Tinnitus Functional Index. There was no group without sound, and sleep itself was not an outcome. In a Japanese clinic, 66% of 100 patients had a sleep disorder, and sleep quality scores improved after counselling and sound generators, but without a comparison group.
So the case for sound at night is plausible and low-risk rather than proven. How to set it up is in sleeping with tinnitus, and the free sound library lets you try options in a browser.
When poor sleep needs more than a new routine
The evidence above supports asking a doctor or audiologist for CBT-I by name when insomnia lasts for weeks; sleeping with tinnitus covers that conversation and when sleep apnea is worth ruling out. A change in the tinnitus itself is a different matter: hearing that drops suddenly over hours to 3 days needs same-day care, and NICE advises being seen within 24 hours (sudden hearing loss explains why). The the when to seek care checklist sorts out other signs, such as a new pulsing sound.