Tinnitus (ringing in the ears): causes, red flags and when to seek help

Tinnitus is the name the NHS gives for hearing noises that do not come from an outside source. The brain is thought to generate phantom sound when its normal input from the ear is reduced or disturbed, much as the brain fills in a missing visual area. That is why tinnitus is so often accompanied by some hearing loss, even when you have not noticed it.

The NHS says the noises may be in one or both ears, or in the head, and may come and go or be present all the time. Tinnitus is usually more noticeable at night and in quiet rooms, when there is less background sound to mask it.

The NHS says it is not always clear what causes tinnitus, but it is often linked to some form of hearing loss, Meniere disease, conditions such as diabetes, thyroid disorders or multiple sclerosis, anxiety or depression, and taking certain medicines. It names some chemotherapy medicines, antibiotics, non-steroidal anti-inflammatory drugs (NSAIDs) and aspirin as capable of causing tinnitus as a side effect.

Other everyday contributors include earwax blocking the ear canal, ear infections, loud noise exposure from work, concerts or headphones, jaw problems and neck tension, and high doses of aspirin. The sound itself helps: a low-pitched roar with fullness and fluctuating hearing suggests Meniere disease, while a high-pitched ring after noise exposure suggests noise damage.

The NHS says to go to A&E or call 999 if you have tinnitus after a head injury, or tinnitus with sudden hearing loss, weakness in the muscles of your face, or a spinning sensation (vertigo). Do not drive yourself.

It says to ask for an urgent GP appointment if you have tinnitus that beats in time with your pulse. Pulsatile tinnitus can arise from changes in blood flow, narrowed arteries, raised pressure inside the head or, rarely, a vascular abnormality, so it is investigated differently from the usual hissing or ringing.

The NHS dizziness page also lists ringing or other sounds in the ears among reasons to see a GP when you are dizzy. Tinnitus in only one ear, especially with hearing loss on that side, is also usually referred for specialist hearing assessment, since a small benign nerve tumour is a rare cause.

The NHS says the GP will look in your ears to see if your tinnitus is caused by something they can treat, like an ear infection or a build-up of earwax, and might check for any hearing loss, and that you may be referred to a specialist for further tests and treatment. Expect questions about which ear, the sound, whether it pulses, hearing change, dizziness, noise exposure, medicines, mood and sleep, and how much it bothers you.

A hearing test (audiogram) is the key investigation. An MRI scan of the inner ear nerves is arranged if tinnitus is one-sided, pulsatile or comes with asymmetric hearing loss. Blood tests for thyroid or anaemia are done if suggested by the history.

The NHS says to try to relax with deep breathing or yoga, improve sleep with a bedtime routine and less caffeine, avoid things that can make tinnitus worse such as stress or loud background noises, and consider joining a support group. It advises not having total silence, because listening to soft music or sounds, called sound therapy, may distract you from the tinnitus, and not focusing on it.

It says if the cause is unknown or cannot be treated, a GP or specialist may refer you for CBT to change the way you think about tinnitus and reduce anxiety, tinnitus counselling, or tinnitus retraining therapy, which uses sound therapy to retrain the brain to tune out the sound. You will usually be offered digital CBT first. Tinnitus retraining therapy may be available on the NHS for severe or persistent tinnitus, though it is unclear if it works for everyone, and it is widely available privately. If you have hearing loss, hearing aids may be recommended, and often reduce tinnitus as well.

The NHS says to see a GP if you have tinnitus regularly or constantly, if it is getting worse, or if it is bothering you, for example affecting your sleep or concentration or making you feel anxious and depressed. Do not put up with tinnitus that is affecting your mood; help is available.