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Editor's
Note: Contains updates and links to articles written
after original publication date.
Alternative
Medications and Other Treatments
for Tinnitus: Facts From Fiction
by
Michael D. Seidman, MD
and Seilesh Babu, MD
HISTORY
 Since
the dawn of human existence, nutritional supplements,
herbs, and phytonutrients have been used to heal.
Forty percent of Americans have used some form of
complementary/integrative medicine (CIM) to treat
a wide variety of chronic conditions. In 1998, expenditures
on CIM in the USA had approached 27 billion dollars
and increased to 32 billion in 2000.1
This paradigm shift, to alternative forms of therapy,
is gaining acceptance for many reasons including:
patients' dissatisfaction with conventional medical
care, which is perceived to be too intent on curing
rather than preventing disease; traditional medicines
having too many side effects and hence, are often
ineffective. Conversely, the conventional western
physician is typically skeptical of CIM practices
because of the lack of double-blind randomized placebo-controlled
studies. This is a particularly difficult problem
because the pharmaceutical industry is not routinely
interested in funding studies to assess the efficacy
of herbs and other supplements since patent protection
is unlikely. Coupled with the fact that the cost to
bring a compound through the US Food and Drug Administration
averages $300 million or more, it is no wonder that
studies into this arena are rare.2
Conventional
medical fields, such as allopathic and osteopathic
medicine, were only introduced in the US less than
200 years ago. This subsequently led to the rapid
reduction in CIM therapies as these were suddenly
viewed as antiquated and a form of quackery. The unfortunate
result of this skepticism was the over-emphasis solely
on conventional medicine as a means to heal and cure.
In the best scenario, tapping into knowledge from
both CIM and conventional medicine would likely lead
to better overall care of our patients.
The
use of medication for treatment of tinnitus has largely
been varied and anecdotal. Drugs such as nicotinic
acid, carbamezepine, baclofen, and others have been
tried and even tested in double-blind placebo-controlled
trials (Table 1) .28 Few have
been shown to be significantly beneficial in adequately
formulated studies. Lidocaine has been studied in
several carefully controlled double-blinded studies
and shown to be beneficial. However, lidocaine must
be given intravenously, has a very short half-life,
and is often accompanied by undesirable side effects.
Oral analogs of lidocaine, such as tocainide and flecainide
acetate did not improve. tinnitus.21
A double blind, placebo-controlled study using Melatonin
(3mg at bedtime) was found to have no advantage over
placebo in relieving tinnitus. However, among patients
reporting difficulty sleeping attributable to their
tinnitus, 46.7% reported an overall improvement after
melatonin compared with 20.0% for placebo.21
Benzodiazepines also may provide relief, especially
for patients with concurrent depression. In one study,
76% of patients taking alprazolam had a reduction
in the loudness or their tinnitus while only 5% of
the placebo group showed benefit.29
Education, counseling, tinnitus retraining therapy,
and medications remain the major modalities in the
treatment of tinnitus. Many individuals have reported
that these have provided either resolution of, or
produced the greatest decrease in, their symptoms.
The
objective of this chapter is to discuss treatment
alternatives for chronic tinnitus. Examples include
variations in diet, vitamin supplementation, herbal
medicine, and other modalities. While these options
are considered alternative to many traditional physicians,
it should be emphasized that there is currently no
cure for tinnitus. The treatments discussed in this
chapter have been beneficial for some people who have
constant tinnitus, especially those whose tinnitus
failed to respond to traditional treatment modalities.
Altering one's diet has been shown to improve tinnitus
in some patients. Many patients with tinnitus report
that certain supplements seem to have a variable benefit
in reducing their symptoms. Nutrient supplementation
to treat tinnitus has been extensively studied. The
following have generated the most interest and support:
magnesium, calcium, potassium, lipoflavonoids, B vitamins,
copper, selenium, zinc, and manganese. Herbal remedies
for this ailment include Ginkgo biloba, Black cohosh,
mullein, and cornus. Other treatments, such as laser
light therapy, enzymatic therapy, tinnitus retraining,
and vibrational therapy will also be discussed.
 VITAMIN
B COMPLEX
The
B complex vitamins are a family of nutrients that
have been grouped together due to the interrelationships
in their function within human enzyme systems, as
well as their distribution in natural food sources.
Deficiency in these vitamins has been shown to result
in tinnitus18, and supplementation
may improve the symptom. The B vitamins are water
soluble and easily absorbed, except vitamin B-12,
whose absorption is enhanced by intramuscular injection
or sublingual application. Nevertheless, oral B-12
supplementation will still lead to increased serum
levels. Unlike fat-soluble nutrients, most B complex
vitamins cannot be stored in the body, and must therefore
be replaced daily from food sources or supplements.
B
vitamins function as coenzymes to facilitate human
metabolism and energy production. They maintain healthy
skin, eyes, muscle tone, and support the functions
of the liver and central nervous system. They are
also important in helping to deal with depression,
stress and anxiety. Normally B vitamins are taken
as a complex, but a single B vitamin may be indicated
to treat a particular disorder. Deficiency in B vitamins
may also result in lethargy, anemia, nervousness,
skin and hair problems, lack of appetite, poor night
vision, and hearing loss.20
Editor’s
Note: Arches Tinnitus Stress Formula contains high
potency B-Complex vitamins which are very helpful
for maintaining proper functioning of the nervous
system, reducing stress and anxiety and, in some people,
may help in reducing tinnitus. Of particular importance
to our readers is that deficiencies of B vitamins
result in hearing loss. Another important study showed
that deficiency of B vitamins directly resulted in
tinnitus. You can read an article on how
B vitamins work in our Tinnitus Info Section.
Citrus bioflavonoids found in the Stress Formula have
shown to be helpful in reducing tinnitus - Barry Keate
VITAMIN
B1 (Thiamine)
Vitamin
B-1 (thiamine) is a nutrient with a critical role
in maintaining a healthy central nervous system. Adequate
thiamine levels can dramatically affect cognitive
function by maintaining a positive mental attitude
and enhancing learning abilities. Conversely, inadequate
levels of B-1 can lead to vision problems, mental
confusion, and loss of physical coordination. Vitamin
B-1 is required for the production of hydrochloric
acid, forming blood cells, and for maintenance of
healthy circulation. It also plays a key role in converting
carbohydrates into energy, and in maintaining proper
muscle tone of the digestive and cardiovascular systems.
A chronic deficiency of thiamine will lead to beriberi,
a devastating and potentially deadly disease of the
central nervous system. Beriberi is diagnosed clinically
by peripheral neuropathy, cardiovascular and cerebral
dysfunction, which include congestive heart failure
and dementia. Due to improved diets and the widespread
use of supplements, beriberi is rare in developed
countries, with one important exception. Beriberi
symptoms are occasionally seen in chronic alcoholics
due to the destructive effect alcohol has on B-1.
Thiamine levels can also be affected by ingestion
of antibiotics, sulfa drugs, caffeine, antacids, and
oral contraceptives. A diet high in carbohydrates
can also increase the need for B-1.
Food
sources high in thiamine include beans, eggs, brewers
yeast, whole grains, brown rice, and seafood. In supplemental
form, B-1 is generally found in a combination with
vitamins B-2, B-3, B-6, pantothenic acid, and folic
acid. There are no known toxic effects from vitamin
B-1, and any excess is excreted from the body. The
Recommended Dietary Intake (RDI) for B-1 is 1.5 milligrams,
though more typical daily intake ranges from 50 to
500 milligrams per day.37
Some
patients have noted that Vitamin B-1 supplements relieves
their tinnitus.16 The mechanism
of action seems to be via a stabilization effect on
the nervous system, especially in the inner ear. Dosages
ranging from 25 to 500 mg per day have been used.
VITAMIN
B-3 (NIACIN)
Vitamin
B-3 (also called niacin, niacinamide, or nicotinic
acid) is an essential nutrient required for proper
metabolism of carbohydrates, fats, and proteins, as
well as for the production of hydrochloric acid. Vitamin
B-3 also supports circulation, healthy skin, and aids
in the functioning of the central nervous system.
Because of its role in supporting the higher functions
of the brain and cognition, vitamin B-3 also plays
an important role in the treatment of schizophrenia
and other mental illnesses, and stabilizing cognitive
functions. Adequate levels of B-3 are vital for the
proper synthesis of insulin, and the sex hormones,
estrogen, testosterone, and progesterone. Natural
food sources for Vitamin B-3 include beef, broccoli,
carrots, cheese, corn flour, eggs, fish, milk, potatoes,
and tomatoes. However, foods containing vitamin B-3
provide minimal amounts of this vitamin.
A
deficiency in vitamin B-3 can result in pellagra,
a disorder characterized by malfunctioning of the
nervous system and gastrointestinal upset. Classically,
the three cardinal symptoms are diarrhea, dementia,
and dermatitis. Recently, niacin has been embraced
by the medical community for its ability to safely
lower cholesterol and triglyceride serum levels. The
dosing required is between 500 to 2000 mg daily. Doses
exceeding 1000mg can lead to hepatoxicity and is more
common in the timed-release niacin supplements. Thus,
when recommending doses in this range, liver function
tests need to be monitored.37
Niacin,
at any dose, may result in a niacin flush, a natural
reaction that is harmless but that can be uncomfortable.
A niacin flush will generally result in a burning,
tingling, and itching sensation, accompanied by a
reddening flush that spreads across the skin of the
face, arms, and chest, typically lasting five to sixty
minutes.37 A non-flush form
of niacin now exists which may be better tolerated
by some patients, but this is the form that is more
apt to cause potential liver problems.
There
is no accepted standard niacin dosing for tinnitus.
Typically, the senior author recommends beginning
at 50 mg twice per day. After two weeks, if there
is no improvement, the patient increases the dose
by 50 mg at each interval to a maximum dose of 500
mg twice per day. Higher doses can be recommended,
but it is advised to monitor liver function tests.
Niacin may provoke migraine headache attacks in some
people and appropriate warning is justified. High
doses should be used with caution in pregnant women.
Mega doses of pure niacin can aggravate health problems,
such as stomach ulcers, gout, glaucoma, and diabetes
mellitus.
Unfortunately,
there is no clinical proof for the effectiveness of
niacin in treating tinnitus. This is inherently difficult
to prove due to a possible "placebo effect" arising
from the niacin flush sensation rather than any therapeutic
value of the underlying vasodilation. The senior author
has noted a favorable response to niacin in some patients.
There have been other anecdotal reports of the benefit
of niacin in treating tinnitus.16
Some
health care providers advocate taking niacin in combination
with thiamine. The 1994 text on myofascial pain, Trigger
Points, states that niacin without thiamine seems
to provide little relief for tinnitus.35
However, this has not been the senior author's experience.
The combination dosing is basically two parts niacinamide
for each one-part thiamine. Some supplements will
come balanced in this proportion.
There
have also been reports of niacin working in combination
with lecithin, a group of phospholipids that yield
two fatty acid molecules, and one molecule each of
glycerophosphric acid and choline after hydrolysis.
Lecithin is found in nervous tissue, especially myelin
sheaths, and in the plasma membrane of plant and animal
cells. The theory is that the lecithin, being an emulsifier,
helps disperse the buildup of fats in the capillaries,
and the niacin helps dilate the capillaries to allow
the lecithin in. The phosphatidyl choline portion
of lecithin, however, is a precursor of acetylcholine
and should be avoided in people who are manic-depressive
because it may worsen the depressive phase. Compelling
evidence exists from experiments in our laboratory
demonstrating that aged rats supplemented with a diet
rich in phosphatidyl choline have improved auditory
sensitivity when compared to placebo supplemented
rats. Furthermore, study of the subjects' mitochondrial
function reveals a statistically significant improvement
in mitochondrial energy production in the treated
groups compared to placebo.15
VITAMIN
B-12
Vitamin
B-12, also referred to as cobalamin and cyanocobalamin
(see editor's note after this section), is a micronutrient
that is water soluble like other B-vitamins. However,
unlike the other B-vitamins which are not stored in
the body, vitamin B-12 is stored for up to nine months
in the liver and kidneys. The RDI for vitamin B-12
is 2 micrograms for adults, 2.2 micrograms for pregnant
women, and 2.6 micrograms for nursing mothers.7
Vitamin B-12 is not found in vegetables, but can be
found in pork, blue cheese, clams, eggs, herring,
kidney, liver, seafood, and milk.
It
has been estimated that 5 to 10% of persons over the
age of 65 years are deficient in vitamin B-12. With
newer and more sensitive tests available, deficiency
states have been found in as many as 15-20% of the
population.34 This deficiency
state is most likely secondary to absorption difficulties
as well as a deficient nutritional intake. There may
be some correlation between the decline in vitamin
B-12 levels and the increasing prevalence of tinnitus
in the elderly.
Vitamin
B-12 is an important coenzyme required for the proper
synthesis of DNA and new cell formation. It also works
synergistically with vitamin C to aid in proper digestion
and absorption of foods, protein synthesis, and the
normal metabolism of carbohydrates and fats. Additionally,
B-12 prevents nerve damage by contributing to the
formation of the myelin sheath. Vitamin B-12 also
maintains fertility, and helps promote normal growth
and development in children.
Metabolites,
including cobalamin, are involved in stabilizing neural
activity. Vitamin B-12 is an essential cofactor for
methylation of myelin basic protein and cell membrane
phospholipids. Cobalamin deficiency has been shown
to be a factor involved in neuronal dysfunction. It
is therefore logical to assume that a relationship
between tinnitus, which might involve neuronal dysfunction,
and vitamin B-12 deficiency may exist. In the senior
author's experience, several patients who were motivated
to attempt nutritional supplementation with B-12 noted
significant improvement in their tinnitus. However,
still others have reported no such benefit. A deficiency
of vitamin B-12 can result in pernicious anemia, characterized
by megaloblastic anemia, lack of intrinsic factor,
inability to absorb vitamin B-12, and increased risk
for esophageal webs and cancer. Since vitamin B-12
can easily be stored in the body and is only required
in minute amounts, symptoms of severe deficiency usually
take three to five years to appear. When symptoms
do arise, usually in mid-life, it is likely that deficiency
was due to digestive disorders or malabsorption rather
than poor diet. However, it is well known that the
elderly have a reduced dietary intake, which may predispose
them to nutritional deficiencies. Furthermore, strict
vegetarians (vegans) who do not consume any foods
of animal origin need to supplement their diets with
this nutrient since B-12 comes almost exclusively
from animal sources.
Vitamin
B-12 is available in supplemental form. Due to relatively
poor gastric absorption, B-12 can be taken as a sublingual
tablet or by injection. Supplements range in strength
from 50 micrograms to 2 milligrams. Mega dose vitamin
B-12 toxicity is unknown, and any excess is excreted
from the body.31 One can measure
serum B-12 or serum methylmalonic acid for levels
of this vitamin. The normal range of B-12 in a healthy
population is 150 to 900pg per milliliter.
Experimental
studies and clinical observations have related tinnitus
to demyelination of nerve fibers and to a distorted
resting state of spontaneous neural activity. Shemesh
et al. showed a high prevalence (47%) of vitamin B-12
deficiency in patients with chronic tinnitus when
a criterion of deficiency is set at 250 pg/mL and
lower.31 Serum cobalamin deficiency
was more widespread and severe in the tinnitus group
associated with noise exposure. This suggested a relationship
between vitamin B-12 deficiency and dysfunction of
the auditory pathway. Deficiency also results in peripheral
and central neurological pathology. Decreased methionine
production due to cobalamin deficiency can lead to
a sensory demyelinating neuropathy.
Abnormalities
of the nervous system in the absence of hematologic
disorders and normal results of the Schilling test
have been reported in 28% of 141 consecutive patients
with abnormally low serum cobalamin. The Schilling
test assesses the absorption of free cobalamin and
also the absorption of free cobalamin with intrinsic
factor. In many instances, the actual cause of the
deficiency is difficult to identify. It might be a
result of inadequate dietary intake, a minor alimentary
dysfunction, or a nutrition-metabolic disturbance.
Supplemental cobalamin was found to show some relief
in several patients with severe tinnitus.32
Editor’s
Note: Since the initial publication of this article,
researchers have found that the form of Vitamin B-12
utilized by the body is methylcobalamin. Widely uses
and less costly cyanocobalamin must be converted to
methylcobalamin in the liver for proper utilization.
Methylcobalamin has been shown to protect against
glutamate-induced excitotoxic neuronal damage. Neuronal
damage caused by excess glutamate is one of the primary
causes of tinnitus and worsens existing tinnitus.
You can view an article
on B-12 and methlycobalamin in our Tinnitus Info
Section. Arches
Tinnitus B-12 Formula contains 1000 mcg of methylcobalamin,
the superior form - Barry Keate
VITAMIN
B-6 (PYRIDOXINE)
Vitamin
B-6 is a coenzyme involved in the metabolism of carbohydrates,
fats, and proteins and the manufacturing of hormones,
red blood cells, neurotransmitters, enzymes and prostaglandins.
It is also required for the production of serotonin,
a neurotransmitter that controls our moods, appetite,
sleep patterns, and sensitivity to pain. A deficiency
of vitamin B-6 can quickly lead to insomnia and profound
malfunctioning of the central nervous system. Common
symptoms of deficiency can include depression, vomiting,
anemia, renal stones, dermatitis, lethargy, and increased
susceptibility to diseases due to a weakened immune
system.37 Among its many benefits
include helping to maintain healthy immune system
functions, protecting the heart from cholesterol deposits,
and preventing renal stone formation. It is also beneficial
in the treatment of carpal tunnel syndrome, premenstrual
syndrome, night leg cramps, allergies, asthma, arthritis,
and dizziness.37
Supplemental
B-6 is commonly used as a treatment for nausea, morning
sickness, depression, and tinnitus. Natural foods
that are highest in vitamin B-6 include brewers yeast,
carrots, chicken, eggs, fish, avocados, bananas, brown
rice, and whole grains. The RDI for vitamin B-6 is
2 mg per day. Most B-complex formulas contain between
10 to 100 mg of vitamin B-6. Vitamin B-6 is one of
the few vitamins that can be toxic. Doses up to 500
mg per day are uncommon but safe. However, doses above
2 grams per day can lead to irreversible neurological
damage. Doses exceeding this level should not be used
unless the patient is under the treatment of a physician.
Vitamin B-6 supplements should not be taken by Parkinson's
disease patients treated with L-dopa, since vitamin
B-6 can diminish the effects of L-dopa in the brain.
Most of the vitamin B-complex supplements appear to
work on tinnitus in some patients by providing a stabilizing
effect on the nerves centrally and peripherally. Only
anecdotal evidence exists regarding this treatment
method.
FOLIC
ACID
Folic
acid is a water-soluble nutrient belonging to the
B-complex family. The name is derived from the Latin
word "folium," since this essential nutrient was first
extracted from green leafy vegetables, or foliage.
Sometimes referred to as Vitamin M, folic acid was
originally extracted from spinach in 1941 and was
found to be an effective treatment for macrocytic
anemia.20
Folic
acid is a vital coenzyme required for RNA and DNA
synthesis. Adequate levels are essential for energy
production and protein metabolism, for the formulation
of red blood cells, and for the proper functioning
of the intestinal tract. Furthermore, studies have
demonstrated that folic acid reduces homocysteine
levels and therefore reduces the risk of heart disease.37
Additional
studies revealed that maternal folic acid intake leads
to a significant reduction in the incidence of fetal
neural tube defects such as spina bifida. This effect
was noted with a daily folic acid intake of at least
400 micrograms, the current RDI. Folic acid may also
prove to be effective in the prevention and treatment
of uterine cancer.3
Folic
acid deficiency affects all cellular functions, but
most importantly it reduces the body's ability to
repair damaged tissues and grow new cells. Tissues
with the highest rate of cell replacement, such as
red blood cells, are affected first, leading to anemia.
Deficiency leads to sore tongue, cracking at the corners
of the mouth, gastrointestinal distress, diarrhea,
and poor nutrient absorption, leading to stunted growth,
weakness and apathy.37 Folic
acid deficiency is common and can develop within a
few weeks to months of lowered dietary intake. The
greatest need for increased folic acid intake is in
those who are under mental and physical stress, such
as alcoholics, and people taking oral contraceptives,
aspirin, or anticonvulsants. Foods highest in folic
acid include barley, beans, beef, bran, brewers yeast,
brown rice, cheese, chicken, green leafy vegetable,
milk, salmon, tuna, wheat germ, and whole grains.
Though
not generally regarded as toxic, large doses of folic
acid can cause allergic skin reactions, and should
be avoided by people being treated for hormone-related
cancers. High doses of folic acid can also cause problems
in those taking phenytoin for a convulsive disorder.
Folic acid seems to also have a stabilization effect
on the nervous system. This might explain the anecdotal
evidence regarding the supplementation of folic acid
in certain patients to alleviate their tinnitus. The
dosages ranged from 400 to 800 mcg per day and usually
required 2 to 3 months of trial to achieve results.16
Minerals
ZINC
 Zinc
is a component of over 100 enzymes. Among these are
DNA polymerase, RNA polymerase, and tRNA synthetase.
Mild deficiency causes growth retardation in children.
More severe deficiency is associated with growth arrest,
hypogonadism, infertility, poor wound healing, diarrhea,
dermatitis, alopecia, behavioral changes, taste and
smell disorders, and tinnitus. Zinc seems to function
in certain areas to influence neurotransmission and
to inhibit binding of peptides and other ligands to
their neuroreceptors.
The
RDI of zinc in adults is 15 mg. The majority of the
zinc content in humans is bound to proteins in the
tissues. In plasma, zinc is primarily bound to albumin;
less than 2% of zinc is found free. The zinc level
in serum is not the best parameter, but is the most
reliable one for assessing zinc balance in the body.
Nearly 99% of total-body zinc is inside the cells.
The remainder is in plasma and extracellular fluids.25
Studies
on rodents have shown a high content of zinc in the
inner ear. Other studies have found that the human
cochlea has the body's greatest concentration of zinc.
These findings have given rise to speculation of the
role of zinc in inner ear function. A correlation
between hypozincemia and tinnitus has been reported.22
In an uncontrolled trial by Gersdorff et al., zinc
was found to reduce tinnitus.9 Zinc given in doses
ranging from 10 to 25mg has delivered good results
in some patients shown to be hypozincemic based on
blood tests. In a double-blind, randomized study,
Paaske showed little correlation between hypozincemia
and tinnitus; and no significant improvement in subjective
tinnitus using zinc supplements.25
Ochi,
et al. demonstrated a significant decrease in zinc
levels in patients suffering from tinnitus, and that
supplementation with doses of 34-68 mg of zinc over
two weeks significantly decreased tinnitus. Excellent
results have been found with the combination of niacin
and 25 mg zinc gluconate twice a day.22 If tinnitus
is of recent onset, complete resolution is possible.
With longer duration, the tinnitus can be diminished
with these nutrients in some people.
Supplementation
of 90-150 mg per day has been shown to be beneficial
in some cases. Zinc therapy when prescribed is often
accompanied by frequent blood tests to monitor copper
levels. Copper and zinc compete for intestinal absorption,
so chronic ingestion of zinc may result in copper
deficiency. Acute zinc toxicity can usually be induced
by ingestion of greater than 200 mg of zinc in a single
day and is manifested by epigastric pain, nausea,
vomiting, and diarrhea.
Editors
Note: A more recent clinical study conducted in Ankara,
Turkey by Arda, et. al. showed that 50 mg of zinc
daily reduced subjective tinnitus in 82% of patients.
See
complete clinical study on zinc. - Barry Keate
 CALCIUM
By enhancing neural transmission, calcium supplementation
has been shown to improve tinnitus symptoms in certain
patients. Calcium is one of the most abundant minerals
in the human body and accounts for between two to
three pounds of total body mass. Adequate dietary
sources are necessary for building and maintaining
strong bones and teeth, as well as regulating muscle
growth. In conjunction with magnesium, calcium also
plays a pivotal role in the regulation of electrical
impulses in the central nervous system and in the
activation of various hormones and enzymes required
for proper digestion and metabolism. This vital mineral
is also necessary to support bodily functions such
as blood clotting and maintaining blood pressure.
There is also strong evidence that calcium plays a
role in colon cancer, and those with low intake of
calcium and Vitamin D are more prone to this disease.
Half
of America's adults are not getting enough calcium
according to a panel of experts assembled by the National
Institutes of Health (NIH). The federal committee
estimates that calcium deficiencies, resulting in
brittle bones and fractures, are costing the U.S.
health care system $10 billion annually. The report
states that the recommended daily allowance for calcium
is too low, leading to weak bones in children, adults,
and especially, elderly women.37
Calcium
absorption occurs primarily in the small intestines,
and requires adequate amounts of Vitamin D. The current
RDI of calcium is 800 mg for adults, 1,200 mg for
premenopausal women, and 1,500 mg for postmenopausal
women unless they are taking estrogen. Those with
kidney disorders should not take calcium supplements
unless directed to do so by their health care professionals.
Key dietary sources of calcium include dairy foods,
green leafy vegetables, and seafood. Absorption of
dietary calcium can be drastically reduced by consuming
large amounts of foods such as cocoa, spinach, kale,
rhubarb, almonds, and whole wheat products which are
high in oxalic acid, and are known to interfere with
calcium absorption. Taking antibiotics such as tetracycline,
or aluminum containing antacids can also result in
lower absorption of calcium. Alcohol, sugar, and coffee
can also affect the body's levels of this mineral.
Some
patients have experienced improvement in their tinnitus
after starting a regimen of vitamin and nutrient supplementation,
which included calcium.16 Dosages ranged from 1000
to 1500 mg per day for several months.
MAGNESIUM
Magnesium is the fourth most abundant cation in the
body after sodium, potassium, and calcium, and the
second most prevalent intracellular cation. The normal
body content is around 1000 mmol, 50-60% of which
is in bone. Extracellular magnesium accounts for only
1% of total body magnesium. The normal serum concentration
ranges between 0.75 and 0.95 mmol/L.40
Magnesium
is essential for the function of important enzymes,
including those related to the transfer of phosphate
groups and every step related to the replication and
transcription of DNA and the translation of mRNA.
This cation is also required for cellular energy metabolism
and has an important role in membrane stabilization,
nerve conduction, ion transport. Deficiency can thus
result in a variety of metabolic abnormalities and
clinical consequences, including tinnitus.1
Magnesium
has been shown to prevent hearing loss in a study
by Attias et al. Three hundred healthy, young male
military recruits undergoing two months of basic training
were studied. The trainees were repeatedly exposed
to high levels of impulse noise. Each recruit received
daily either 167 mg of magnesium (as magnesium aspartate)
or a placebo (sodium aspartate). Permanent hearing
loss was significantly more frequent and more severe
in the placebo group. It can be inferred, therefore,
that magnesium may have a positive role on tinnitus.1
Magnesium
is a potent glutamate antagonist. There is evidence
in the literature that antagonism of glutamate receptors
has an effect on auditory sensitivity and on tinnitus.37
Furthermore, a highly motivated patient elected to
have magnesium sulfate delivered to the inner ear
for her severe unilateral cochlear tinnitus. While
the MgSO4 was being delivered, her tinnitus ceased.
Unfortunately, it recurred shortly after cessation
of the perfusion.16
Animal
studies have shown that noise exposure causes magnesium
to be excreted from the body.40 Supplementation with
magnesium might reduce the ototoxicity from this noise
and thus reduce the likelihood of new onset tinnitus.
Few studies have documented that magnesium supplementation
improves tinnitus, but many patients have had relief
with this method.
Editors
Note: View a more complete look at Magnesium
and its relation to health and tinnitus. - Barry
Keate
MANGANESE
Manganese is a mineral that is required in small amounts
to manufacture enzymes necessary for the metabolism
of proteins and fats. It also supports the immune
system, regulates blood sugar levels, and is involved
in the production of cellular energy, reproduction,
and bone growth. Manganese works with vitamin K to
support blood clotting and aids in digestion. As an
antioxidant, manganese is a vital component of Superoxide
Dismutase, an enzyme that is the body's main front-line
defense against damaging free-radicals.30 While there
is no RDI for manganese, the average intake of manganese
is between 2 to 9 milligrams per day. Foods high in
manganese include avocados, blueberries, nuts and
seeds, seaweed, egg yolks, whole grains, legumes,
dried peas, and green leafy vegetables.
Along
with the B-complex vitamins, manganese helps control
the effects of stress while contributing to ones sense
of well being and it is possible that this may have
a stabilizing effect on patients suffering from tinnitus.
A deficiency in intake can retard growth, cause seizures,
lead to poor bone formation, impair fertility, cause
birth defects, and lead to nervous symptoms, such
as tinnitus. Investigators are also looking at new
links between manganese deficiency and skin cancers.
Anecdotal evidence has shown that manganese supplementation
may reduce the symptom of tinnitus.16
SELENIUM
Selenium is a component of several enzymes, most notably
glutathione peroxidase and superoxide dismutase. These
enzymes prevent oxidative and free radical damage
of various cell structures. Evidence suggests that
the antioxidant protection conveyed by selenium operates
in conjunction with vitamin E, since deficiency of
one seems to enhance damage induced by a deficiency
of the other. Selenium also participates in the conversion
of thyroid hormone to its active form.
The
RDI is 50 to 70 mcg/day.20 Deficiency is rare in North
America. Such individuals have myalgias, cardiomyopathies,
and nervous system abnormalities. Keshans disease,
a fatal heart disease found in children living in
certain sections of China, occurs where selenium intake
is limited. Toxicity is associated with nausea, diarrhea,
alterations in mental status, and peripheral neuropathy,
observed in adults who inadvertently consumed between
1500-2700mg. One may check RBC glutathione peroxidase
activity, or plasma selenium concentrations for deficiency,
although neither are entirely accurate.23 Supplementation
may take up to six months to show improvement in symptoms
such as tinnitus.
HYPERBARIC
OXYGEN THERAPY
Oxygen deprivation and/or reduced cochlear blood flow
has been suggested as a potential cause of hearing
loss and tinnitus in response to intense noise exposure
or secondary to sudden sensorineural hearing loss.
Hyperbaric oxygen therapy (HBO) may be considered
in these situations. It may be more effective for
recent onset rather than long-term cases. Since tinnitus
and hearing loss are not approved indications for
the use of HBO, insurance will not normally cover
the treatments. HBO therapy is in common use in European
countries for the management of sudden hearing loss
and noise-induced hearing loss and their results have
been positive.6
The
theory behind HBO treatment is based on the assumption
that tinnitus is caused by reduced oxygenation to
the inner ear. Studies at Munich Technical University
have shown that pure oxygen treatment under high air
pressure can increase oxygen saturation in the inner
ear up to 500%. In Russia this method reportedly has
been used extremely successfully for many years. In
Moscow alone, there are about 40 pressure chambers
in use for this currently.14
Editors
Note: Read an extended discussion of
Hyperbaric Oxygen Therapy. - Barry Keate
VINPOCETINE
and VINCAMINE
Vinpocetine is a derivative of vincamine, which is
an extract of the periwinkle. Although they have many
similar effects vinpocetine has more benefits and
fewer adverse effects than vincamine. It is a vasodilator
and increases blood flow to the brain and improves
the brain's use of oxygen.33
These drugs have not yet been approved in the United
States for treatment, however they are available in
Europe and South America in over-the-counter preparations.
Although it is not available in North America as a
pharmaceutical, it is available in low doses in over-the-counter
supplements. Only anecdotal evidence exists that these
medications can suppress tinnitus.16
Vinpocetine
is a derivative of vincamine and is three to four
times more potent at improving cerebral circulation
and is overall twice as potent as vincamine in humans.
Vinpocetine has wide ranging effects and can be used
to treat stroke and improve memory, menopausal symptoms,
macular degeneration, impaired hearing, and tinnitus.
The usual oral starting dose is 40mg three times daily,
to be followed by a maintenance dose of 1 tablet three
times daily for a longer period of time. Vinpocetine
has not been reported to interact with other drugs.
In
humans, the effect of vinpocetine on cerebral blood
flow is uncertain, with some investigators reporting
no change, and others reporting an increase. It has
been reported that vinpocetine can be used safely
to treat patients with "chronic cerebral dysfunction
of vascular origin". Vinpocetine is also a powerful
memory enhancer. It facilitates cerebral metabolism
by improving cerebral microcirculation, enhancing
brain cell ATP production, and increasing utilization
of glucose and oxygen.33 Vincamine has also been used
to treat a remarkable variety of conditions related
to insufficient blood flow to the brain, including
vertigo and Meniere's syndrome, difficulty in sleeping,
mood changes, depression, hearing problems, high blood
pressure and lack of blood flow to the eyes.5 Vincamine
has also been used for improving memory defects and
inability to concentrate. Vincamine has extremely
low toxicity and is inexpensive.
HYDERGINE
Hydergine is reported to increase mental abilities,
prevent damage to brain cells from hypoxia, and may
even be able to reverse existing damage to brain cells.
Hydergine is an extract of ergot, a fungus that grows
on rye.38 Midwives in Europe traditionally used ergot
with birthing mothers to lower their blood pressure.
Scientists have analyzed ergot alkaloids since the
late 1940s in search of blood-pressure medications.
Studies in the elderly population uncovered cognition-enhancing
effects of hydergine and it is now a popular treatment
for all forms of senility in the U.S., and is used
to treat a plethora of problems elsewhere in the world.
Hydergine
probably has several modes of action for its cognitive-enhancement
properties. Its wide variety of reported effects include
the following: increases blood supply and oxygen to
the brain, enhances brain cell metabolism, protects
the brain from free-radical damage during decreased
or increased oxygen supply, and reduces symptoms of
dizziness and tinnitus.10
Hydergine may cause mild nausea, gastric disturbance,
and headache. There are no serious side effects reported
with hydergine use. It is nontoxic even at very large
doses. However, it is contraindicated for individuals
with acute or chronic psychosis, or those with a known
sensitivity to the medication. Overdosage may, paradoxically,
cause an amnestic effect.
Hydergine
is available in the United States with a doctor's
prescription. Hydergine has not undergone rigorous
scientific tests to prove its effectiveness for tinnitus
reduction. However, in Europe many patients have been
using Hydergine with good success in relieving their
symptoms.
HERBAL
REMEDIES
Patients who suffer from the condition of tinnitus
have the opportunity to explore the horizon of complementary/integrative
medicine (CIM) in pursuit of a treatment regimen that
may relieve many of their agonizing symptoms. As is
the case in the treatment of other chronic diseases,
conventional pharmacotherapy represents only one avenue
upon which the physician may venture. In an attempt
to relieve the symptoms which plague the common tinnitus
patient, the patient may want to explore non-conventional
treatment options.
For
more than 2000 years, herbal regimens have been employed
in the treatment of medical conditions.10 Combinations
of Chinese herbs, exotic fruits, plant roots, and
seed oils have proven to be effective in the treatment
of many medical disorders, where conventional medical
therapy has failed. What many of these herbal treatment
regimens lack, is solid medical evidence, in the form
of double-blind research experiments, which would
legitimize the utilization of these non-conventional
treatments. However to the suffering patient, whose
treatment regimens have been met with failure, perhaps
anecdotal accounts of effective treatments are proof
enough to justify an alternative approach.
GINGKO
BILOBA
Gingko biloba, or maidenhair, is the oldest living
tree on earth. Gingko biloba leaves have been used
therapeutically by the Chinese for centuries for the
treatment of asthma and bronchitis. Ginkgo biloba
was believed at one time to have magical powers. Today,
Ginkgo is felt by many to have a legitimate medicinal
role. The important components of Ginkgo are flavonoids
and terpenoids. These have been shown to inhibit the
action of Platelet Activating Factor (PAF). The putative
active ingredient has been isolated as EGB761 and
there have been many studies related to its effectiveness
in a variety of medical disorders.11 It has been shown
to increase circulation throughout the body. Numerous
studies have shown the efficacy of ginkgo on intermittent
claudication, cerebral insufficiency, and tinnitus.12
Typical
dosages range from 120-480mg per day, divided equally
at mealtime. In western countries a standardized 50:1
concentrate of 24% gingko flavonoids is used, either
in liquid or capsule form. Most studies showed that
between 30-70% of subjects had improved cognitive
abilities over a 6-12 weekperiod.11 No serious side
effects were observed, and any minor side effects
were not statistically significant compared to subjects
treated only with placebo.
In
terms of tinnitus, a study by Hobbs in 1986 provided
statistical significance for the effectiveness of
treatment with ginkgo extract for tinnitus; the ringing
completely disappeared in 35% of the patients tested,
with a distinct improvement in as little as 70 days.11
Similarly, when 350 patients with hearing defects
due to advanced age were treated with ginkgo extract,
the success rate was 82%. Furthermore, a follow-up
study of 137 of the original group of elderly patients
5 years later revealed that 67% still had better hearing.12
Opinions
differ as to the efficacy of this herbal remedy. While
certain sufferers of tinnitus "swear by"
Ginkgo biloba, others claim that it has no effect
on their symptoms. The results of the first large-scale
double-blind randomized prospective study (1121 volunteers
at Birmingham University in the U.K.) on the efficacy
of Ginkgo in tinnitus treatment, was published in
2001. The patients in this study received either 150mg
of Ginkgo or placebo in a randomized fashion for 12
weeks. The results did not show significant effect
in treating tinnitus, however the dose employed was
approximately 65% less than what has been shown to
be of benefit.8
Published
studies have shown that 120 to 240mg twice per day
of pharmaceutical-grade ginkgo extract can alleviate
tinnitus.19 A controlled study showed that ginkgo
extract caused a statistically significant decrease
in behavioral manifestation in the animal model of
tinnitus. Another human study showed that in patients
suffering from cerebrovascular insufficiency, gingko
extract produced a significant improvement in symptoms
of vertigo, tinnitus, headache, and forgetfulness.11,5
One
of the appealing aspects of Ginkgo biloba with regard
to the treatment of tinnitus, has been the fact that
it is relatively inexpensive, and has negligible side
effects, such as increase risk for epistaxis. There
has been one report of a woman who used Ginkgo for
approximately 2 years who developed a subdural hemorrhage.16
However,this substance has been used for more than
2000 years without severe side effects. As with any
medication, the physician should take a careful history
before recommending Gingko as it may potentiate hemorrhage
in people taking coumadin or heparin. The German Commission
E, which is considered an excellent reference for
the medicinal use of therapeutic herbs, rates Ginkgo
as positive and recommends 240 mg twice per day for
tinnitus and vertigo.5 The response to Ginkgo can
occur within weeks, but is most noticeable within
3 to 4 months.
Combined
application of soft-laser irradiation of the cochlea
and intravenous supply of Ginkgo extract for 4 weeks
was found to be beneficial in 20-50% of patients in
one study.26 The mechanism of the soft laser is unknown,
but it is known to cause an athermic stimulation of
biochemical processes induced by light. Increased
ATP production occurs in yeast fungus cultures irradiated
with the soft laser, yet it is unclear if it is this
same mechanism in human inner ear cells. Soft-laser/Ginkgo
therapy promised to be very effective in chronic tinnitus.
Ginkgo provides a better oxygen supply and the laser
acts directly on the flavo proteins to activate "repair
mechanisms." Plath and Olivier showed that in
single cases, tinnitus reduction can be attained and
they deduced that combined soft laser and Gingko application
can be helpful in some patients suffering from severe
tinnitus. However, Wedel et al showed no significant
improvement with these treatments compared to placebo.39
The
variable response to herbs including Gingko raises
the concern of whether all preparations are the same.
In the senior author's experience, it is clear that
some of the less expensive brands were ineffective
and had a higher rate of gastrointestinal upset. When
these patients were then changed to a more respected
or well-known brand, these side effects were ameliorated
and the patients’ response was typically better.
Over the past several years, we have been recommending
Arches
Tinnitus Relief Formula, as their formulation
is highly standardized and appears to be effective
for some patients. Ginkgo is not effective in every
patient with tinnitus, but the risk to benefit ratio
would suggest that a trial with Ginkgo is reasonable.
Editor’s
note: A retrospective overview of 19 clinical trials
published in Germany provides conclusive proof of
the effectiveness of Ginkgo biloba for tinnitus. The
complete overview can be seen here.
Read about Why
Some Ginkgo Products Don't Work for Tinnitus -
What you need to know before starting. - Barry Keate
Black
Cohosh (Cimicifuga Racemosa)
The popular herb Black cohosh comes from the root
of the North American forest plant Cimicifuga racemosa.
It derives its name from a description of the rhizome,
which is black and rough. Also known as black snakeroot,
bugbane, bugwort and squawroot, Black cohosh has an
extensive history of safe use by Native Americans
who revered it as a remedy for a host of common ailments.5
Native Americans employed Black cohosh as an effective
treatment for fatigue, neuralgia, rheumatism, sore
throat, asthma, bronchial spasms, bronchitis, and
whooping cough. Mixed with chamomile, ginger, and
raspberry leaf, Black cohosh has been used for centuries
by women to stimulate menstrual flow, ease the strains
of childbirth, and confer relief from the symptoms
of menopause.
Contemporary
herbalists also hold Black cohosh in high regard as
an antispasmodic for relief from cramps, muscle pains,
and menstrual pains. With its mildly sedative and
relaxing effect, Black cohosh is also used to treat
anxiety, nervousness, and chronic tinnitus. Some patients
have reported improvement in their tinnitus while
using this herbal preparation.
The active ingredients in Black cohosh appear to be
chemical derivatives mimicking some of the effects
of estrogen. It was also found to contain the glycoside
acetein, a steroidal derivative that is effective
in lowering blood pressure in animals.21 Black cohosh
also contains compounds that support its use as a
sedative and as an anti-inflammatory agent.
There
are few known health concerns regarding Black cohosh,
but consuming large amounts are known to cause nausea,
dizziness and vomiting. Expectant mothers should only
use black cohosh under the supervision of a health
professional, since it has a reputation of stimulating
the uterus to contract, and large doses could lead
to premature birth. Black Cohosh has traditionally
been used to calm the nervous system by nourishing
blood vessels28 and it is theorized that it may improve
cerebral blood flow, providing relief from tinnitus
in some patients. Dosages range from 20 to 40 mg per
day in liquid form for this ailment.
Mullein
(Verbascum Densiflorum)
Mullein is ubiquitous, and its velvety leaves, rod
like stem and brilliant yellow flowers are its striking
characteristics. Mullein has a long history of use
in herbal medicine. Its botanical family name -- Scrophulariaceae
-- is derived from scrofula, an old term for chronically
swollen lymph glands, later identified as a form of
tuberculosis. Initially, this herb gained a favorable
reputation as a respiratory remedy. Physicians from
India to England touted it as a treatment for coughs
and chest congestion, alleviating irritation, earaches,
and tinnitus.24
In
a 1986 survey of folk medicine in Indiana, researchers
discovered that this herb remains "very popular"
for respiratory complaints.24 There has been little
research on mullein itself, and even less research
into its treatment of tinnitus. However, some herbalists
have shown benefit in patients suffering from severe
tinnitus, claiming it to be very valuable. Mullein
seems to have a slight diuretic effect and may alleviate
inflammation. To brew a medicinal tea, use 1 to 2
teaspoons of dried leaves per cup of boiling water.
Boil for ten minutes and strain leaves. 1 teaspoon
contains approximately 0.5g of the drug. The dosage
reported to provide relief from tinnitus seems to
be 3 to 4g per day. There have been no reports of
mullein causing adverse effects, except for mild irritation
of the skin when in contact with the living plant.21
CORNUS
Cornus, which is also known as Asiatic cornelian
cherry fruit and Asiatic dogwood, is grown in several
parts of China. The fruit is harvested in October
and November when it becomes purplish red, and is
fat, thick, soft and seedless. Available at Chinese
pharmacies, Asian food markets, and some Western health
food stores, cornus is taken internally for excessive
urination, incontinence, impotence, lightheadedness,
excessive sweating, and excessive menstrual bleeding.
Formerly, it was in use as a replacement for quinine.28
Preparation of the combination formula alluded to
above, which is used in the treatment of tinnitus,
requires the consultation of an herbalist. Chinese
herbalists advise against the usage of cornus in combination
with several other herbs, including platycodon, siler,
and stephania.
Cornus
(Cornus officinalis) alone does not seem to relieve
the symptoms of tinnitus, but when used in combination
with Chinese foxglove root and Chinese yam proves
to be effective in the treatment of tinnitus, low-back
pain, and urinary frequency.21
OTHER
THERAPIES
Wobenzym
Wobenzym is a group of proteolytic enzymes including
Pancreatin, Trypsin, Chymotrypsin, Bromelain, Papain,
and Rutosid. It was initially developed by Dr. Ransberger
in 1959 with MUCOS Pharma to fight cancer. Dr. Ransberger
brought the formula to Germany and since then has
pioneered the medical use of the systemic enzymes.
This remedy has shown effectiveness for arthritis,
throbbing pains, and tinnitus. It seems to be an “alternative”
to aspirin and has shown some benefit to recovering
from a myocardial infarction.27
Studies
in Europe have been conducted on Wobenzym, backing
the findings of Dr. Ransberger. Studies show Wobenzym
as safe with none of the adverse side effects of aspirin,
ibuprofen and other NSAIDs (Non-Steroidal Anti-Inflammatory
Drugs).36 It has also been shown to improve red blood
cell viscosity, improve circulation to damaged areas,
and have anti-inflammatory properties.36 Whether or
not Wobenzym can positively influence the symptom
of tinnitus has not been adequately studied, but some
patients have noted relief.
Laser
Therapy
In the cochlea, all of the auditory processes require
energy in the form of ATP. It takes place in the auditory
cells of the cochlea and is connected with movements
of hair-like receptors on the cellular membrane and
other processes within the cells of the inner ear.
ATP is produced by the mitochondria inside each cell.
If the cochlea is acutely or chronically over strained,
its sensory cells and their various cellular organs
are affected as well, and they inevitably lose part
of their functional capacity. The cells are suffering
from a lack of ATP. This continuous lack of ATP within
the inner ear cells of the cochlea leads to either
a gradual or sudden impairment of the entire hearing
organ.
Using
low-level laser therapy, Dr. Lutz Wilden in Germany,
has been able to produce a positive biological reaction
regardless of the dysfunction involved in the inner
ear. The electromagnetic energy released by the oxidation
of nutrients is utilized as a source of primary energy
for the production of the cellular fuel ATP.
The
mitochondria can - in addition to the absorption of
the released metabolic energy - utilize both the photons
of the natural solar radiation (apparent bio-stimulative
effect of sunlight on human cells) and the photons
of low-level laser light (clinically proven bio-stimulative
effect of low level laser light on human cells) as
a source of primary energy. Dr. Wilden uses two separate
beams on the mastoid bone and one beam down the ear
canal simultaneously. This delivers a calculated 4
j/cm2 to the cochlea.42 The additional ATP triggered
by the light may have some healing value for the damaged
inner ear hair cells. This therapy may be more beneficial
in patients in the early stages of tinnitus as it
may have more benefit in damaged cells than dead ones.
Editor’s note: For
an in-depth article on laser therapy, click here
- Barry Keate
Beta
Histine Hydorchloride (SERC)
Beta histine hydrochloride, also known as Serc, is
not approved for use in the USA. This drug has been
used in Canada and Europe for patients with severe
vertigo from Meniere’s disease and in some patients
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