The major tinnitus guidelines agree on CBT and on hearing aids for people with hearing loss, and mostly against drugs and supplements; they split on sound therapy, brain stimulation such as rTMS, and ginkgo.
A 2017 systematic review of the five guidelines it identified, from Denmark, Germany, Sweden, the Netherlands and the United States, found a high level of consistency on hearing tests, CBT, hearing aids where there is hearing loss and advice against medicines, and differences mainly over imaging and sound therapy. Its title asked whether different teams reach the same conclusions. Mostly they do. The useful part is where they do not, and why.
This page compares seven guidelines. Three have their own walkthroughs: the 2014 AAO-HNS guideline, the 2024 VA/DoD guideline and NICE's NG155.
The seven guidelines, briefly
- AAO-HNS, United States, 2014. The American Academy of Otolaryngology–Head and Neck Surgery Foundation's guideline covers adults whose tinnitus has lasted 6 months or longer and bothers them. The VA/DoD work group's 2025 journal summary called it the most recent US guideline before theirs.
- VA/DoD, United States, 2024. The Departments of Veterans Affairs and Defense made 25 recommendations using GRADE, and none is strong: the work group says a lack of randomised trials and study design limitations left it without the evidence for one.
- NICE NG155, United Kingdom, 2020. Published on 11 March 2020. A 2023 review notes that NICE rated evidence with GRADE but attached no explicit grade to its recommendations, and was the only one of 10 guidelines to report resource implications.
- European multidisciplinary guideline, 2019. Written by clinicians and researchers in TINNET, an EU-funded research network. Only randomised trials and systematic reviews counted towards a recommendation; anything weaker meant an automatic "no recommendation".
- German S3 guideline, 2021. From the German Society for Otorhinolaryngology, Head and Neck Surgery and many partner societies, published in English in 2022. S3 is the German label for a guideline that has been through every element of systematic development. Each recommendation records the panel's percentage agreement, and dissents are printed alongside.
- Japanese guideline, 2019. Edited by the Japan Audiological Society, authorised by the Oto-Rhino-Laryngological Society of Japan and published in May 2019, with an English summary in 2020. The 2023 review found its panel was made up only of otorhinolaryngologists.
- Korean guideline, 2026. Published online in July 2026 and developed by a panel of eight otorhinolaryngologists, a neurologist, a psychiatrist and an audiologist, using searches up to 2025, GRADE, and a modified Delphi vote needing 80% agreement. Its abstract rates most of the evidence low or very low certainty.
They do not share a grading scale. The 2023 review of 10 guidelines found no two used the same combination of grading tools, so a "strong recommendation" in one is not the same unit as in another.
Where they agree
CBT
- AAO-HNS: recommends CBT for persistent, bothersome tinnitus.
- VA/DoD: suggests CBT by a trained provider (weak for), the strongest grade it gives anything.
- NICE: consider a stepped approach: digital CBT provided by psychologists, then group therapy such as mindfulness-based cognitive therapy, ACT or CBT, then individual CBT.
- European: a strong recommendation, and the only strong recommendation it gives any treatment.
- German: a strong recommendation, on its highest evidence level.
- Japanese: its English summary calls psychological therapy and CBT an option, noting that psychotherapy can be hard to provide alongside ENT care in Japan; a 2023 comparison by Langguth and colleagues lists it as a strong recommendation.
- Korean: conditionally recommended (Grade B).
A 2023 review of 10 guidelines found counselling and CBT were the only treatments recommended by every guideline that addressed them. The effect behind that consensus is modest. The 2023 comparison cites a Cochrane estimate of 10.91 points on the 100-point Tinnitus Handicap Inventory, just above the 7-point change taken as meaningful, on low-certainty evidence and with no data at 6 or 12 months. CBT for tinnitus covers the trials.
Hearing aids, when there is hearing loss
- AAO-HNS: recommends a hearing aid evaluation where hearing loss is documented.
- VA/DoD: suggests hearing aids for adults with hearing loss.
- NICE: offer amplification where hearing loss affects communication, consider it where it does not, and do not offer it without hearing loss.
- European: a weak recommendation for people with hearing loss, and not for people without it.
- German: recommended for chronic tinnitus with hearing loss.
- Japanese: a strong recommendation where tinnitus comes with hearing loss, per the 2023 comparison.
- Korean: conditionally recommended (Grade B).
This agreement rests more on judgement than on trials: the 2023 review found three guidelines made the recommendation despite a lack of evidence on its effectiveness for tinnitus. Hearing aids for tinnitus sets out who tends to benefit.
Explanation first, drugs last
Education comes first almost everywhere. The US guideline recommends educating people about management strategies, the VA/DoD suggests educational counselling, the European guideline says clinicians should educate patients, Germany's makes counselling the basis of treatment, and Japan's gives educational counselling its highest priority.
Drugs aimed at the tinnitus itself are advised against wherever they are covered:
- AAO-HNS: against antidepressants, anticonvulsants, anxiolytics and intratympanic medications for routine treatment.
- VA/DoD: suggests against anticonvulsants, antidepressants, antiemetics, antithrombotics, betahistine, intratympanic corticosteroids and NMDA receptor antagonists.
- European: a weak recommendation against.
- German: a strong recommendation against, upgraded because of possible side effects even where the evidence on individual drugs was only moderate.
- Japanese: drug administration should be avoided.
- NICE: addresses only betahistine, and says do not offer it.
The shared exception is depression or anxiety alongside tinnitus. The European and German guidelines say these may need drug treatment in their own right, and the 2023 comparison lists Japan's guideline as supporting antidepressants where depression or anxiety coexists, on low evidence. Drugs for tinnitus covers the trials.
They also agree on testing. NICE says to offer everyone with tinnitus a hearing assessment, and the US guideline recommends a prompt one when tinnitus is one-sided, persistent or comes with hearing difficulty. NICE says to consider the Tinnitus Functional Index to assess how tinnitus affects someone, and not to offer pitch and loudness matching to assess tinnitus; for monitoring progress, the VA/DoD suggests questionnaires such as the same index and suggests against loudness matching.
Where they split
Sound therapy, the widest gap
- AAO-HNS: an option.
- VA/DoD: suggests the therapeutic use of sound for self-care, but finds insufficient evidence on altered music such as notched music.
- Korean: conditionally recommended to reduce distress (Grade B).
- NICE: no recommendation; it asked for research on sound therapy combined with tinnitus support.
- European: no recommendation. It says sound may help for acute relief but is not considered an effective long-term intervention.
- German: sound therapy should not be practised, noise generators should not be recommended, and notched music should not be practised.
- Japanese: the 2023 comparison records no recommendation for sound generators, while the guideline's own summary describes sound therapy as the approach more likely to be delivered in Japanese ENT practice.
The evidence underneath is thin. The German guideline cites a 2018 Cochrane review of 8 studies and 590 participants that found no device superior to placebo or to education and counselling; the 2014 US guideline predates that review. Weak evidence became an option, a suggestion, a conditional recommendation, no recommendation and a recommendation against. Sound therapy for tinnitus and notched sound therapy cover the trials.
Tinnitus retraining therapy, which combines counselling and sound, also splits, though more narrowly. Japan recommends it on low evidence, Korea conditionally recommends it, Germany says it can be considered long term without noise generators, the VA/DoD names it as an example of sound enrichment with directed education, the European guideline makes no recommendation, and NICE does not address it by name.
rTMS and tDCS
- Against: the AAO-HNS and European guidelines on TMS, and Japan's as recorded in the 2023 comparison; Germany's on both rTMS and transcranial electrical stimulation. Germany's rTMS vote carried 92% agreement, with a dissent from its psychiatry society saying rTMS can be considered.
- Undecided: the VA/DoD finds insufficient evidence on rTMS and tDCS, the European guideline makes no recommendation on transcranial electrical stimulation, and NICE made a recommendation for research on neuromodulation.
- For: Korea conditionally recommends tDCS or rTMS as an add-on treatment (Grade B).
Langguth and colleagues point out that CBT's effect of 10.91 points on the Tinnitus Handicap Inventory is similar to meta-analytic effects for rTMS (7 to 8 points), tDCS (9.69) and acupuncture, yet every guideline recommends CBT and none of the ones they compared recommends the others. Korea's 2026 guideline has since broken that pattern. Several of the authors declare ties to neuromodulation companies, while stating none relates to the paper. TMS and tDCS have their own articles.
Ginkgo and supplements
- Against: the AAO-HNS (ginkgo, melatonin, zinc and other supplements), the VA/DoD (ginkgo, supplements and nutraceuticals), the European guideline (which notes ginkgo can interact with blood thinners), Germany's (supplements strongly against, ginkgo among the drugs not recommended), and Japan's, which the 2023 comparison records under its general advice against pharmacotherapy.
- Silent: NICE.
- Different: Korea says ginkgo may be considered for subjective tinnitus (Grade B), while strongly recommending against routine zinc and vitamin supplements.
Ginkgo biloba for tinnitus traces where that disagreement comes from.
Smaller splits
- Acupuncture: no recommendation from the AAO-HNS or European guidelines, insufficient evidence for the VA/DoD, and a recommendation against it in Germany's.
- Cochlear implants: the VA/DoD suggests them for candidates; Germany strongly recommends them for profound hearing loss or deafness, including in one ear; the European guideline makes no recommendation for tinnitus itself and recommends implants only for people who meet the hearing-loss criteria for candidacy.
- Low-level laser therapy: the VA/DoD suggests against it and Germany says it should not be practised.
Why they reach different verdicts
- Age. Twelve years separate the US otolaryngology guideline from Korea's. Langguth and colleagues put date first among the reasons guidelines differ, since it decides the evidence available, and the 2023 review notes that Germany's 2021 revision turned uncertain positions on rTMS and tDCS into recommendations against.
- What to do with thin evidence. Some guidelines give no recommendation when evidence is weak, others recommend against or call it an option on similarly weak evidence. The review stresses that "no recommendation" and "recommendation against" are different verdicts; NICE adds a third, the research recommendation.
- Method and reporting. Of 10 guidelines, 7 searched the literature systematically, none reported involving a methodologist, and only one defined harms of treatment as an outcome in advance.
- Who writes it. Langguth and colleagues argue that clinicians may favour the treatments of their own discipline, which makes committee make-up matter.
The warning signs they share
On prompt assessment, the guidelines that address it agree. The US guideline's strong recommendation against scans applies only to tinnitus that is not one-sided, does not pulse and comes without focal neurological signs or uneven hearing loss. NICE says to offer imaging for pulsatile tinnitus, to refer immediately for sudden neurological symptoms such as facial weakness, uncontrolled vertigo or suspected stroke, and within 24 hours for hearing loss that developed over 3 days or less in the past 30 days. Korea recommends imaging for pulsatile tinnitus or asymmetric hearing loss.
NICE also says tinnitus with a high risk of suicide needs immediate referral to a crisis mental health team; if that is you now, contact emergency services or a crisis line. The when to seek care checklist sorts which signs are urgent, and sudden hearing loss explains why days matter.
Using the comparison
- Where they agree, on CBT, a hearing assessment and hearing aids for hearing loss, it is reasonable to ask for them.
- Where they split, the evidence is thin. That does not make a treatment wrong to try, but it is fair to ask what evidence supports it and what a course costs.
- Where they agree against, as with drugs aimed at the tinnitus itself, it is fair to ask why your case differs.
The treatment comparison shows each option beside the AAO-HNS and VA/DoD positions, and how tinnitus is diagnosed describes a full assessment.