The VA/DoD Tinnitus Guideline (2024), in Plain English

In June 2024 the US Department of Veterans Affairs and the Department of Defense published their first joint clinical practice guideline for tinnitus. It matters more than most documents of its kind, because tinnitus is the single most common service-connected disability in the VA system and this guideline governs how that population is treated.

It contains 25 recommendations. Not one of them is strong.

Start with the weakness, because it is the finding

The work group says it plainly. Because of rigorous adherence to GRADE methodology — and specifically a lack of randomised controlled trials and study design limitations — it "did not have the evidence to make strong recommendations for this CPG".

That is not a criticism of the guideline. It is the guideline being honest about the field it is summarising. Twenty-five recommendations, every one weak or non-committal, from a group that reviewed the evidence systematically and declined to overstate it.

Anyone selling a tinnitus treatment with confidence is claiming to know something this document could not establish.

What it suggests doing

Nine recommendations are weak for — meaning the balance of evidence favours them, without the certainty to insist:

1. Validated questionnaires to monitor management — the Tinnitus Functional Index or Tinnitus Handicap Inventory, tracked over time.
2. Educational counselling to reduce the functional impact of tinnitus.
3. Hearing aids for tinnitus management in adults with hearing loss.
4. Cochlear implantation for adults who meet candidacy requirements.
5. Cochlear implants over bone conduction devices or CROS hearing aids, in single-sided deafness where the patient qualifies for either.
6. Therapeutic use of sound for tinnitus self-care.
7. CBT by a trained provider for adults with bothersome tinnitus.
8. Sound therapy combined with CBT, delivered by a multidisciplinary team.
9. Sound enrichment with ongoing directed tinnitus education by an audiologist.

Two patterns are worth noticing in that list. Everything on it is either a device that restores hearing, a structured psychological therapy, or sound plus education — the same three things this site's treatment comparison rates highest. And several of the entries are combinations rather than single interventions, which is a quieter finding than it looks: the guideline's stronger endorsements attach to sound with therapy and sound with education, not sound alone.

What it suggests against

Four recommendations are weak against:

• Psychoacoustic measures — loudness matching, minimum masking level — for monitoring whether tinnitus management is working.
• Low-level laser therapy, which this site covers in its own article and reaches the same place from the trial data.
• Ginkgo biloba, dietary or herbal supplements, and nutraceuticals.
• Anticonvulsants, antidepressants, antiemetics, antithrombotics, betahistine, intratympanic corticosteroid injections, and NMDA receptor antagonists.

That last one is a long list, and it lines up almost exactly with the drug trials article on this site, with betahistine and intratympanic steroids named specifically.

The first one deserves a note here, because this site publishes a pitch match tool. The guideline is not saying pitch and loudness matching are worthless — it is saying they should not be used to judge whether treatment is working. That is a real distinction and a fair one: what matters clinically is whether the tinnitus is interfering less, which is what the questionnaires in recommendation 1 measure, not whether a matched tone moved a few decibels.

Where it says the evidence runs out

Twelve recommendations say there is insufficient evidence to recommend for or against, which is a different verdict from "does not work" and is frequently reported as though it were the same thing:

• Web-based or app-based self-management
• Computer-based games or training programs for self-care
• CROS hearing aids in single-sided deafness
• Implantable bone conduction devices in single-sided deafness
• Auditory cognitive training, such as frequency discrimination or auditory attention training
• Sound therapy with altered music, including notched music therapy and spectrally altered music
• ACT, mindfulness-based therapies and MBSR, listed together and unranked
• Repetitive transcranial magnetic stimulation (rTMS)
• Transcutaneous electrical nerve stimulation (TENS)
• Transcranial direct current stimulation (tDCS)
• Acupuncture

Two of those are worth pausing on. Notched music therapy appears in a lot of sound therapy marketing; the general therapeutic use of sound is recommended weakly for, and the specific altered-music variants are not, which is a distinction the marketing does not make. And mindfulness and ACT get a weaker verdict than CBT — which is consistent with what this site's own meditation and ACT articles find, and is a statement about the number and quality of trials rather than about the approaches themselves.

The one recommendation about the neck and jaw

Recommendation 22 suggests a multidisciplinary approach to assessment and treatment where bothersome tinnitus occurs with temporomandibular disorder, cervical spine dysfunction, or both, to reduce the functional impact of the tinnitus.

That is the guideline endorsing the somatic pathway this site covers in somatic tinnitus, TMJ disorder and physical therapy — and specifically endorsing the multidisciplinary version of it rather than any single manual technique.

How it fits with the other guideline

The site cites the American Academy of Otolaryngology–Head and Neck Surgery's 2014 guideline more often, because it is the older and more foundational document. The two agree wherever they overlap:

• CBT — AAO-HNS recommends it; VA/DoD suggests it, weak for.
• Hearing aids where there is hearing loss — AAO-HNS recommends an evaluation; VA/DoD suggests them, weak for.
• Sound therapy — AAO-HNS lists it as an option; VA/DoD suggests it, weak for.
• Ginkgo and supplements — AAO-HNS recommends against; VA/DoD suggests against.
• Anticonvulsants and antidepressants — AAO-HNS recommends against; VA/DoD suggests against.
• Intratympanic medication — AAO-HNS recommends against; VA/DoD suggests against.
• Acupuncture — AAO-HNS gives no recommendation; VA/DoD says insufficient evidence. The same verdict in two vocabularies.

The VA/DoD document is broader: it covers implantable devices, neuromodulation, manual therapy and how to monitor management, none of which the 2014 guideline addressed.

What to do with this

• If a clinician offers something on the "weak for" list, that is the guideline being followed. Weak is the strongest verdict anything received.
• If something is on the "insufficient evidence" list, that is not a refusal. It means the trials to decide have not been done well enough, and it may still be reasonable to try — with expectations set accordingly.
• If something is on the "against" list, the burden is on whoever is recommending it to explain why your case differs.
• Ask for the questionnaire. Recommendation 1 is that management is monitored with a validated measure. If nobody has ever given you a Tinnitus Functional Index or Tinnitus Handicap Inventory score, there is no baseline against which anything you try can be judged — and this site's free impact self-check is not a substitute for that, though it will tell you roughly where you stand before you go.