by Barry Keate
Many people with tinnitus have difficulty sleeping. The impact of tinnitus on affected individuals is very similar to the impact of insomnia on those without tinnitus. Because of this, many tinnitus patients are prescribed benzodiazepine medications to help them get to sleep. This creates new problems of addiction and disturbed sleep patterns. There are ways to get a good night’s sleep without the negative effects of prescription medications through the use of the natural hormone melatonin and Cognitive Behavioral Therapy.
In today’s environment of social distancing and isolation due to the COVID-19 pandemic. Stress levels have increased leading to worsening tinnitus and increased insomnia.
The Insomnia Connection
The International Classification of Sleep Disorders criteria for chronic insomnia include problems with initiating or maintaining sleep for at least three months that occur at least three times per week, in addition to impairment in daytime functioning. Chronic insomnia can affect up to 70% of people with tinnitus. The greater the tinnitus severity the more likely the patient will have insomnia or a sleep problem. They may not only have ringing in the ears but also a critical sleep disorder that can be life altering when combined with tinnitus. (1)
Benzodiazepine medications for Sleep Disturbance
Many physicians in the US prescribe benzodiazepine medications such as Xanax, Valium, Klonopin, etc. to help people get to sleep. These medications can be addicting and withdrawing from benzodiazepine presents difficulties, with the withdrawal symptoms being the same as, or worse than, the symptoms for which they initially took the medication.
A discussion of these medications used as sleeping pills is included in the book, “Tinnitus Retraining Therapy” by Drs. Pawel Jastreboff and Jonathan Hazel. “The very frequent consequence of sleep disturbance is that many patients are taking sleeping pills. This has the negative effect of interfering with normal sleep patterns: decreasing the proportion of the rapid eye movement (REM) stage of sleep that is essential for rest. Patients might be unconscious for a longer time than without medications but will not necessarily experience more REM sleep…It is important to recognize the negative side effects of such drugs, the possibility of development of dependence on them and the fact that they will not help tinnitus in the long term.”(2)
The Importance of REM Sleep
The two main stages of sleep are Rapid Eye Movement (REM) and non-Rapid Eye Movement sleep. REM sleep typically occurs during 20-25% of normal sleep time, around 90-120 minutes a night. During this stage, the eyes move rapidly in many directions. At the same time, muscle paralysis occurs. REM sleep is a mixture of an excited brain state and muscular immobility.
REM sleep is crucial for the consolidation of memory and learning. It plays an important role in the development and maintenance of the central nervous system and allows the brain to learn, grow and adapt to changing circumstances. REM sleep occurs during the period of visual dreaming and is necessary for the integration of daytime experiences into the subconscious.
REM sleep deprivation leads to psychological disturbances such as anxiety, irritability and difficulty concentrating. These conditions lead to increased sensitivity to tinnitus and reduced tolerance of it.
Melatonin for Insomnia and Tinnitus Relief
Melatonin is a human hormone created in the pineal gland. It is responsible for regulating sleep-wake cycles, blood pressure control and several other functions. Production of melatonin in humans decreases as a person ages. It is also inhibited by light to the retina and is increased by darkness. Melatonin is primarily inhibited by blue light. This includes television screens, compact fluorescent lights, smartphones and laptops, which emit mainly blue light. The American Medical Association issued a policy stating, “…exposure to excessive light at night, including extended use of various electronic media, can disrupt sleep or exacerbate sleep disorders. (3)
Supplemental melatonin has been shown in numerous clinical studies to help reduce insomnia and induce a good night’s sleep. One of the most important studies on the use of melatonin to aid sleep and also reduce tinnitus came from the Ear Research Foundation in Sarasota, FL. (4) In a placebo-controlled trial they found, “among subjects reporting difficulty sleeping attributable to their tinnitus, 46.7% reported an overall improvement after melatonin…”. They concluded, “Melatonin has been shown to be useful in the treatment of subjective tinnitus. Patients with high Tinnitus Handicap Inventory scores (a common way of measuring tinnitus severity) and/or difficulty sleeping are most likely to benefit from treatment with melatonin. In light of its minimal side effects, melatonin should be part of the physician’s armament in the treatment of tinnitus.”
Another study showed, “A significantly greater decrease in tinnitus matching and Self Rated Tinnitus scores from baseline was observed after treatment with melatonin relative to the effect observed with placebo.” And, “Melatonin is associated with a statistically significant decrease in tinnitus intensity and improved sleep quality in patients with chronic tinnitus.” (5)
Read our in-depth article on Melatonin and how it affects both sleep and tinnitus.
Cognitive Behavioral Therapy for Insomnia and Tinnitus Relief
A clinical trial of Cognitive Behavioral Therapy (CBT) on tinnitus and insomnia was conducted in the UK and reported in The Hearing Journal in June of 2020. (6) CBT is a form of psychological counseling that focuses on thoughts, how those thoughts interact with behaviors, and how those behaviors interact with feelings. It provides skills to help reduce internal attention to tinnitus and how to better cope with it.
A total of 417 patients who sought treatment for tinnitus in a UK-based audiology clinic were evaluated. They were given a series of questionnaires including the Insomnia Severity Index (ISI) and enrolled in a full course of CBT training. You can read a more detailed explanation of CBT training and how it can improve tinnitus.
Of the enrolled patients and based on their scores in the ISI test, 10% did not have insomnia, 17 had mild insomnia, 42% had clinically significant insomnia and 31% had severe insomnia.
Responses after the CBT training were; 90% of patients rated the effectiveness of CBT as 7 or above (out of 10), 87% rated their improved ability to manage their tinnitus and insomnia as 7 or above, and 97% rated the acceptability of audiologist delivered CBT as 7 or above.
The authors conclude CBT is acceptable to patients and is an effective tool to help manage tinnitus -related insomnia symptoms.
1 – Colucci, Dennis A. AuD, MA. Insomnia and Tinnitus: A Worrisome Cycle, Hearing Journal, 2017 June – Volume 70 – Issue 6 – pp 43,45.
2 – Jastreboff, PJ. Tinnitus Retraining Therapy (TRT) as a Method for Treatment of Tinnitus and Hyperacusis Patients, J Am Acad Audiol 11: 162-177 (2000).
3 – http://articles.chicagotribune.com/2012-07-08/news/ct-met-night-sleep-20120708_blue-light-bright-light-steven-lockley.
4 – Rosenberg SI, Silverstein H, Rowan PT, Olds MJ. Effect of Melatonin on Tinnitus. Laryngoscope. 1998 Mar;108(3): 305-10.
5 – Hurtuk A, Dome C, et al. Melatonin: Can it Stop the Ringing? Ann Otol Rhinol Laryngol. 2011 Jul; 120(7):433-40.