Drugs, food and drink
Last updated on 11 November 2014
This information has been written to help you understand more about whether any food, drink or drugs you take may have an effect on your tinnitus.
Drugs and tinnitus
Many people with tinnitus worry that certain drugs or medicines may have caused their tinnitus. A browse through a medical textbook or a search on the internet would seem to reinforce that view as there are numerous reports of tinnitus being associated with medication. In fact, when these claims are subjected to proper scientific scrutiny the number of drugs that genuinely cause tinnitus is extremely small.
For the majority of the most commonly prescribed drugs the number of people who report tinnitus while taking the drug is tiny, usually less than 1 in 1000 people. This applies to most drugs for high blood pressure, cholesterol lowering drugs (statins), drugs given for anxiety and most antidepressants. Even those drugs that do cause tinnitus tend to result in temporary tinnitus: once the drug is discontinued the tinnitus usually disappears. Also, where drugs do cause tinnitus the effect is usually dose dependent. In other words, the normal dose that a doctor would prescribe does not cause tinnitus. It is only unusually large doses that result in tinnitus.
Why is it that there are so many reports of drugs causing tinnitus but so few scientifically confirmed cases?
The reasons for this apparent contradiction are interesting. Firstly tinnitus is common and taking medication for one condition or another is also common. It is therefore inevitable that there should be some coincidences and some people will develop their tinnitus while taking certain drugs just by chance. They may then blame the drug even though it is blameless. If the patient reports this to their general practitioner the doctor has a duty to fill in a report card and send it to an organisation called the Medicines and Healthcare Products Regulatory Agency (MHRA). The information is then stored so that other doctors can access it to advise their patients. Thus a small number of reports of tinnitus can label a drug as a “tinnitus causer” even though the tinnitus may have been coincidental to taking the medication.
There is another way that drugs may get accused of causing tinnitus: drugs are administered to treat medical conditions or illnesses. Having the illness that requires treatment is a stressful event. Stress is a well recognised trigger for tinnitus and consequently in many cases it is the stress of the illness rather than the drug used to treat the illness that triggers the tinnitus.
Specific drugs and tinnitus
Nonetheless, there are a small number of drugs that do cause tinnitus. Many of these drugs are only given for serious illnesses where there is no alternative and once again the BTA would like to stress that no-one should alter their medication without first discussing it with the prescribing doctor.
Aspirin in large doses has long been recognised as being able to cause tinnitus and indeed researchers use this property to deliberately produce tinnitus in animal experiments. In the normal small doses used to treat headaches or flu it is very unlikely that aspirin will cause tinnitus. Similarly the tiny doses of aspirin that many middle aged and elderly people take to prevent heart attacks or strokes are extremely unlikely to result in tinnitus.
Aspirin used to be used in much larger doses to treat some rheumatological conditions and when given at these very high doses tinnitus sometimes did occur. However this effect was generally reversible: once the aspirin was stopped or the dosage reduced, the tinnitus disappeared. Such large doses of aspirin are almost never used nowadays as there are more effective, modern, alternative drugs available to treat these conditions.
A very small number of people are unusually sensitive to aspirin and develop reversible tinnitus at very low doses. Clearly such people should avoid aspirin and contact their doctor for advice regarding alternative drugs.
Quinine and some of the other anti-malarial drugs can occasionally cause damage to the ear when given in high or prolonged doses, such as in the treatment of malaria. However, taken in low doses to prevent malaria or to relieve night cramps, this does not usually happen. In the rare cases where people on these low doses of quinine do report tinnitus it is temporary and ceases as soon as they discontinue the medication.
There is a small group of very specialised, powerful antibiotics that can be ototoxic – in other words they can damage the inner ear. This damage can cause hearing loss and a small number of the affected people develop tinnitus as a consequence of this hearing loss. This group is known as the aminoglycoside antibiotics and includes streptomycin and gentamicin (Selimoglu 2007). These drugs are not available as tablets, syrups or other oral preparations and are generally given by injection in hospital for severe, life threatening infections. Damage to the ear only occurs when the amount of the drug in the blood stream exceeds certain levels. For this reason the level is closely monitored by regular blood tests. However, there are certain conditions such as renal failure when the level of the drug can rise unpredictably and allow dangerous levels to be reached. In these rare circumstances, tinnitus can occur.
Aminoglycosides are also a component of some ear drops. These ear drops are only available on prescription: all the ear drops that can be purchased at a pharmacy without a prescription in the United Kingdom do not contain aminoglycosides. Although there is a theoretical risk, aminoglycoside ear drops do not generally cause ear damage and ear specialists are happy to prescribe them in reasonably short courses. However, any patient who is worried about taking such drops should discuss the matter with their doctor – there may be an alternative.
The other main group of drugs which can damage the inner ear are the cytotoxic drugs used in treating cancer. Despite the power of such drugs, damage to the ear is surprisingly uncommon. The main group of cytotoxic drugs that can damage the ear is the group containing platinum, including cisplatin and, to a lesser extent, carboplatin and oxaliplatin. The specialist doctors who prescribe such drugs are very well aware of their potential side effects and usually discuss the matter in great detail prior to treatment. Also, where possible, patients receiving such drugs will have their hearing tested on a regular basis to identify any ear damage at an early stage, before any serious deterioration occurs.
Some other drugs which are occasionally ototoxic are a group of drugs called loop diuretics which are used to increase the production of urine in the treatment of high blood pressure, heart failure and some kidney disorders. Ototoxicity only occurs with large doses and the relatively small dose given for mild or moderate hypertension (high blood pressure) does not cause damage to the ear. Even with large doses such diuretics probably only cause permanent damage when used in combination with other ototoxic drugs.
Idiosyncratic drug reactions
Although the vast majority of drugs do not cause tinnitus in most patients there is a small group of patients who will have an unexpected – or idiosyncratic – reaction to their medication. Any patient who suspects this should discuss the matter with their doctor. There may well be a suitable alternative medication or a different dosage regime that may help.
A number of people with tinnitus associate fluctuations of their tinnitus with taking certain foods. However, an equivalent number of people find that these same substances will actually improve their tinnitus! Information on the internet suggests that many foods can trigger or exacerbate tinnitus. There is some weak evidence that dietary factors can have an influence on Ménière’s disease but this is generally with regard to the dizziness of Ménière’s rather than the tinnitus and is beyond the scope of this fact sheet. For all other types of tinnitus there is no robust research to link foods to tinnitus. Certainly there does not seem to be any foodstuff that definitely causes or exacerbates tinnitus in every person. Whatever reaction someone with tinnitus might notice is likely to be a personal idiosyncratic reaction.
Unfortunately there is no simple test for such reactions. The only way of determining if a foodstuff does affect the tinnitus is to remove it from the diet and then reintroduce it as a challenge. Sometimes it is difficult to identify the likely culprit. In these circumstances it may help to keep a diary of what is eaten and drunk and see if there is any relationship between bad periods of tinnitus and individual foods and drinks. The diary may have to be detailed, specifying what type of meat, vegetable, cheese, fish, and so on, as one particular type of vegetable, for example, may aggravate the tinnitus, where others have no effect. If the diary suggests a particular food, that food should be avoided for a period of seven days. Then the system should be challenged by reintroducing that food, withdrawing it, re-challenging, and withdrawing again. Tinnitus can fluctuate so much that the tests should be repeated several times.
Relying on a single trial withdrawal may end up denying a person some item of food that they would otherwise enjoy and in fact has no adverse effect on the tinnitus anyway. Removing such items from the diet often brings no benefit and the lack of enjoyment of that food then merely adds to the burden of tinnitus. It is important to issue a further word of warning at this point: keeping diaries and going on exclusion diets can sometimes be counterproductive as it encourages people to monitor their tinnitus, which can in turn make it seem louder.
People with tinnitus are frequently told to avoid caffeine containing drinks such as coffee and tea. There is no scientific rationale for this advice. A properly conducted scientific study showed that caffeine was not associated with tinnitus causation. Moreover, the researchers found that withdrawing someone from their usual intake of caffeine did produce side effects, particularly headaches and nausea, and this could potentially worsen pre-existing tinnitus. The sensible advice regarding tea or coffee drinking therefore seems to be to stay on a fairly constant intake and not vary this too much from day to day.
It is often recommended that people with tinnitus should abstain from alcohol, with red wine frequently coming in for special criticism. Once again, there seems little hard evidence to justify these statements. The majority of the evidence that is available suggests that alcohol is more frequently helpful rather than harmful with respect to tinnitus. There have, however, been some pieces of research that have identified particular groups of people such as teenagers for whom alcohol does seem to be associated with increased levels of tinnitus.
As with foods, a trial withdrawal and reintroduction would seem to be the sensible way for an individual to establish whether alcohol is related to the level of tinnitus.
A word of caution needs to be sounded here: some people find that alcohol actually helps their tinnitus. We should all keep our alcohol consumption within safe limits and people with tinnitus are no exception to this rule. The government advises that people should not regularly drink more than 3 to 4 units of alcohol per day for men (equivalent to a pint and a half of 4% beer) and 2-3 units of alcohol per day for women (equivalent to a 175 ml glass of wine).
It has been known for some time that tobacco smoking can contribute to inner ear hearing loss. The position with regard to tinnitus was less clear though recent research suggests that smokers have a small increased risk of developing tinnitus.
Although the BTA cannot condone the use of such substances, there is no evidence that marijuana, cocaine or heroin usage increases the risk of developing tinnitus. Indeed there has been discussion among some patient groups as to whether marijuana could help tinnitus. Although there is not much research on this topic, the evidence that is available suggests that it is not helpful. The use of hallucinogenic drugs and inhalants (solvents) does seem to be associated with increased risk of developing tinnitus.
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Don McFerran FRCS Consultant Otolaryngologist, Colchester Hospital University NHS Foundation Trust
© British Tinnitus Association
Issued March 2013.Version 1.4 Revised November 2014. To be reviewed March 2016
This information has been produced by the BTA and conforms to the Principles and Requirements of the Information Standard.
the number of drugs that genuinely cause tinnitus is extremely small.
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