by Barry Keate
Inflammation causes pain, and reducing inflammation reduces the pain. There are several ways to manage chronic inflammatory pain but the most common is the use of over-the-counter pain medications. These are typically of the class called Non-Steroidal Anti-Inflammatory Drugs (NSAIDs). But can these medications cause or worsen tinnitus and what other options are available? This article will discuss the risks and benefits of different therapies for pain management for people with tinnitus.
NSAIDs and Tinnitus
There are many different NSAIDs in different categories but the prominent ones are aspirin, ibuprofen (e.g. Advil, Motrin) and naproxen (e.g. Aleve). Acetaminophen (e.g. Tylenol) is not considered an NSAID because it has little anti-inflammatory activity. Acetaminophen works primarily in the brain to block pain messages and seems to influence the parts of the brain that help reduce fever. That means it can help relieve headaches and minor pain but it’s not as effective against pain associated with inflammation.
NSAIDs are usually used for the treatment of acute or chronic conditions where pain and inflammation are present. These conditions include osteoarthritis, rheumatoid arthritis, pain due to inflammation and tissue injury, low back pain, headache, migraine, and others.
One of the most frequent questions I am asked by our readers is which of these medications will not increase tinnitus. Unfortunately, the answer is that every one of them has hearing loss and tinnitus listed as potential side effects. This does not mean that everyone using them will develop or worsen tinnitus but the risk is there. Higher use correlates with a higher potential of developing these side effects. For some people tinnitus caused by these medications is temporary while for others, it can become permanent. There is no way to know which will occur.
The risk is much reduced for those who only use painkillers occasionally. I am very lucky in that I don’t have chronic pain such as caused by arthritis, lower back pain or injuries. When I do take pain medication it is usually for a short period. My own personal experience is that I can take a couple of aspirin with no ill effects. I cannot take even a small dose of ibuprofen because it dramatically increases my tinnitus for several hours. I can tolerate acetaminophen well but there are other problems associated with this medication.
Acetaminophen is toxic to the liver in high doses. The most common cause of acute liver failure in the US is from acetaminophen. It accounts for more than 100,000 calls to poison centers, roughly 60,000 emergency room visits and hundreds of deaths in the US each year. (1) Severe liver damage can occur if over 4,000 mg is taken in a 24-hour period and it is recommended to stay well below this maximum amount.
Treating Fever Update:
During the Covid-19 pandemic, a lot of doctors are advising their patients to take Tylenol (i.e. acetaminophen) for fever. This has prompted many questions about using a possibly ototoxic medication for fever if it might increase tinnitus. My answer to this is that while acetaminophen is considered ototoxic, it is on the lower end of the spectrum in how often it causes damage to hearing. Most people will not experience increased tinnitus if they keep the dosage low. Increased dosage will bring an increased risk of hearing damage and potential liver problems.
N-Acetyl Cysteine (NAC) can be used to decrease this risk. NAC is an inexpensive and powerful antioxidant that protects hearing and the liver. In fact, when people present in the emergency room with liver problems related to acetaminophen, NAC is the drug used to reverse the damage. NAC is an over-the-counter medication and taking 1,000 mg twice daily will protect both the ears and the liver. It is still advisable to keep the total acetaminophen dosage below 2,500 mg per day.
Aspirin, Hearing Loss, and Tinnitus
Aspirin is most likely to cause hearing loss and tinnitus at the higher daily doses often taken for chronic pain, such as arthritis. Some people may take 8 to 12 tablets a day for arthritic pain. Aspirin’s potential effect on hearing was first recognized soon after the drug was synthesized more than a century ago. In fact tinnitus and hearing loss are among the side effects sometimes listed in tiny print on the label.
A very recent study, published in the Jan. 2015 issue of Otolaryngology – Head and Neck Surgery consisted of a systematic review of other studies involving 185,155 participants who were regular users of aspirin. It found that those taking 6 full strength aspirin (325 mg) or more per day was associated with worse audiometric results. Participants lost between 4 and 112 dB in hearing. The effect was dose dependent and reversible in the short term. (2)
A large Harvard study of middle-aged female nurses, the Nurses’ Health Study II, published in the American Journal of Epidemiology, found that those who took ibuprofen or acetaminophen on most days of the week had a 20% increased risk of hearing loss and tinnitus. (3)
So, if no over-the counter pain medications are totally safe to use, especially by those who already have tinnitus, what is one to do to relieve pain? What about prescription pain medication?
Prescription Opioid Pain Medications and Tinnitus
As with NSAIDs, there are literally hundreds of variations on these medications. The most popular and widely used of this group are hydrocodone, oxycodone and tramadol. They all can cause hearing loss and tinnitus on their own but are generally prescribed in combination with NSAIDs which compounds the issue.
Hydrocodone with acetaminophen (Vicodin, Norco, Lortab) is the most frequently prescribed painkiller in the US. Other popular painkillers are oxycodone with acetaminophen (Oxycontin) and tramadol (Ultram). Hydrocodone and oxycodone are also available with ibuprofen instead of acetaminophen.
As with NSAIDs taken individually, the probability of hearing loss and tinnitus is dependent upon dosage; longer term use leads to a higher percentage of potential hearing damage.
When I occasionally have need of prescription pain relief, I have good results using the generic form of Norco, hydrocodone and acetaminophen. Others may have a completely different experience. But again, each individual must be very careful to keep the acetaminophen dosage below its toxic level.
There are alternative ways to manage pain without resorting to ototoxic drugs. The rest of this article will address these therapies.
Dietary Changes and Inflammation
Dietary changes can make a big difference in the amount of inflammation in our bodies. These changes may or may not totally eliminate chronic pain from inflammation but, at the very least, they will significantly reduce inflammation and the need for pain medication.
Neil Bauman, PhD, has written an excellent paper: Reducing Inflammation Without Taking Ototoxic Drugs. (4) In this paper, Dr. Bauman lists the 10 worst and 10 best foods for reducing inflammation. I think this list is important enough to include here:
The 10 Worst Inflammatory Foods (reduce or eliminate consumption);
-Desserts made with lots of sugar,
-White carbohydrates (white bread, white rice, white potatoes, etc.),
-Non-diet soft drinks,
-Anything with high-fructose corn syrup,
-Processed meats (bologna, salami, hotdogs, sausage, etc.),
-Fried snack foods (French fries, potato chips, etc.),
-Fast foods, especially the high-fat, high-calorie, high-simple carb foods found in most fast food restaurants,
-Margarine, because it leads to atherosclerosis and fatty deposit diseases,
-Organ meats such as liver because they contain antibiotics, fertilizers and other residues.
The 10 Best Inflammatory Foods (increase consumption);
-Wild salmon, mackerel and other high omega-3 fatty-acid fish,
-Green, leafy vegetables (spinach and kale),
-Cruciferous vegetables (broccoli, Brussels sprouts, cabbage, etc.),
-Deeply pigmented produce, such as sweet potatoes, eggplant and pomegranate, along with carrots plums, oranges, peppers, peas and red grapes,
-Tea – specifically black, green and white teas,
-Cold-pressed fresh oils, especially avocado, flaxseed and olive oils,
-Spices, especially garlic, ginger, turmeric, saffron.
An additional tip is to eat slowly and deliberately. Chewing food completely reduces the inflammation index of the food while wolfing it down increases it.
Dr. Bauman concludes with some sage advice. Making drastic lifestyle changes is difficult and prone to failure. He suggests people start slow and begin by substituting one of the foods in the worst list with one of the foods in the best list. As people continue this gradual dietary change, over time most of the inflammatory foods will be removed and the person should be feeling much better.
Omega-3 Fish Oil for Inflammation and Pain
Fish oil, high in Omega-3 fatty acids, is at the top of the list of the 10 best inflammatory foods. The reason for this is that many clinical trials have shown fish oil to be a powerful anti-inflammatory food. Omega-3 acids are termed Essential Fatty Acids (EFAs) because the body must have them to survive but does not produce them on its own. They must be obtained from the diet or supplementation.
The two primary Omega-3 fatty acids found in fish oil are eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). These are responsible for the many health benefits of consuming fish oil.
A clinical study published in the American College of Nutrition in 2002 shows how Omega-3s are effective in the management of inflammatory and autoimmune diseases. It found that use of Omega-3 fatty acids, “…in chronic inflammatory diseases reveal significant benefit, including decreased disease activity and a lowered use of anti-inflammatory drugs.” (5)
The same study found benefit for a number of inflammatory and autoimmune diseases including, coronary artery disease, major depression, aging, cancer, arthritis, Crohn’s disease, ulcerative colitis, lupus, MS and migraine headaches.
Normal dosages for supplemental fatty acids are 1 – 3 grams per day of combined EPA and DHA to combat inflammation. In order to treat major depression research suggests the dosage should be 3 – 10 grams per day. Fish oil supplements can be purchased at any health food store in capsule form or as natural oil.
Omega-3 fatty acids may totally relieve a lot of inflammatory conditions. At the very least they will help control the discomfort and lead to a large reduction in the need for pain medication.
There is much more to discuss about the health benefits of Omega-3 fish oil. Interested readers should review our article, Omega-3s, Inflammation and Tinnitus.
Other Alternative Pain Remedies for Individuals with Tinnitus
This list and discussion of pain therapies comes from the paper “Alternative Treatments for Chronic Pain” published by WebMD. (6)
Acupuncture – Once seen as bizarre by most medicine practitioners in the West, acupuncture is rapidly becoming a mainstream treatment for pain. Studies have shown that it works for pain caused by many conditions, including fibromyalgia, osteoarthritis, back pain and sports injuries.
Acupuncture is based on the principal that all people have energy called “qi” (pronounced chee) flowing in their bodies along specific meridians. If this energy is not balanced, or is blocked in some locations, the results are pain and disease. Acupuncture is the practice of releasing this energy and freeing the blockages.
Acupuncture can also be helpful for treating tinnitus. Michael Seidman, MD has stated that acupuncture can help up to 40% of tinnitus patients and can be used when other treatments fail. Interested readers can see our article on Acupuncture and Tinnitus.
Yoga – There is evidence that yoga can relieve many kinds of pain, such as fibromyalgia, neck and back pain and arthritis. Yoga also causes the production of GABA in the brain. GABA is an inhibitory neurotransmitter that produces a feeling of calm and wellbeing. GABA is also helpful for the reduction of tinnitus as readers can see in our article How Yoga Increases GABA and Improves Tinnitus.
Biofeedback – This discipline teaches people how to control normally unconscious bodily functions like blood pressure and heart rate. Studies have found it can help with headaches, fibromyalgia and other conditions. As is the case with the above two pain relief measures, biofeedback can also be helpful for tinnitus, as seen in our article Biofeedback and Neurofeedback: Tools to Reduce Tinnitus.
Capsaicin – This is a natural ingredient found in chili peppers. It is available as on over-the-counter cream in most pharmacies. Capsaicin (pronounced cap-say’-sin) reduces the pain and inflammation from arthritis and other causes by warming the skin and blocking pain messages to the brain. It is hot and will produce a burning sensation if it touches the face or eyes. It is very important to wear gloves during application or to wash hands thoroughly afterward.
Mental Health Therapy – Some people with chronic pain reject the idea of seeing a therapist. They think this indicates their pain isn’t real. But depression and chronic pain often go together. Chronic pain can cause or worsen depression and depression can lower a person’s tolerance to pain. Therapy from a trained and licensed specialist can sometimes be a great help for people with chronic pain.
Exercise – Regular physical activity has big benefits for people with many painful conditions. Many studies have found that physical activity can help relieve chronic pain, as well as boost energy and mood.
If you have chronic pain due to an inflammatory condition and are concerned about worsening your tinnitus, don’t reach into the medicine cabinet for a pain reliever. Try one or more of the above therapies. Your ears will be thankful.
1 – http://www.drugwatch.com/tylenol/
2 – Kyle ME, Wang J, Shin J. Ubiquitous Aspirin: A Systematic Review of Its Impact on Sensorineural Hearing Loss, Otolaryngology-Head and Neck Surgery 20152015, Vol. 152(1)23-41.
3 – Curhan S, Shargorodsky J, Eavey R, Curhan G. Analgesic Use and the Risk of Hearing Loss in Women, Am. J. Epidemiol. (2012), August 29, 2012.
4 – https://hearinglosshelp.com/blog/reducing-inflammation-without-taking-ototoxic-drugs/
5 – Simopoulos AP. Omega-3 Fatty Acids in Inflammation and Autoimmune Diseases, J Am Coll Nutr. 2002 Dec;21(6):495-505.
6 – http://www.webmd.com/pain-management/chronic-pain-11/alternative-treatment.