Alprazolam (Xanax) For Tinnitus Treatment: Reducing the Ringing?

Alprazolam is a medium duration-of-action benzodiazepine anxiolytic utilized primarily for the treatment of acute anxiety episodes (e.g. panic attacks).

Because alprazolam functions as a positive allosteric modulator (PAM) of GABA-A receptors, it allows endogenous GABA to bind with increased frequency to agonize receptors – which increases CNS inhibition.

The combination of: neurochemical modulation AND CNS inhibition – likely helps a subset of individuals cope with tinnitus by: (1) reducing tinnitus perception (i.e. loudness) and/or (2) decreasing the psychological burden of tinnitus (e.g. anxiety, hyperarousal, insomnia, panic, etc.).

  • Research has shown that GABA and glutamate abnormalities are present within the auditory cortex of tinnitus patients. (R)
  • It’s reasonable to suspect that alprazolam could modulate both GABA and glutamate (within the brain and auditory cortex) such as to reduce tinnitus perception for some individuals.

In sum, alprazolam likely: (1) Modulates GABA & glutamate neurotransmission in the brain and cochlea; (2) GABA receptors within the cochlea and auditory centers; (3) calms entire CNS & PNS (fight-or-flight response) via inhibition (making tinnitus less perceptible).

Alprazolam for Tinnitus Treatment (Research)

Included below are studies and reports that discuss the impact of alprazolam in the treatment of tinnitus.

 

Jufas & Wood (2015): Alprazolam has equivocal evidence (in the treatment of tinnitus) and a significant side effect profile; strong consideration of another benzodiazepine or class of drug is recommended. (R)

  • Researchers conducted a systematic review to determine the efficacy of benzos for subjective tinnitus – while considering possible side effects.
  • Database searches were performed using the terms “tinnitus” & “benzodiazepines” to find clinical trials evaluating benzos for tinnitus. All studies were evaluated for risk of bias.
  • A total of 6 clinical trials met inclusion criteria for this systematic review.
  • Benzodiazepine use for subjective tinnitus does NOT have a robust evidence base.
    • Clonazepam has the most evidence to support its use and is relatively less likely to lead to abuse because of its longer half-life, but caution is necessary given the other serious side effects.

Jalali et al. (2009): Alprazolam did NOT improve THI (tinnitus handicap inventory) score or sensation level of loudness significantly, but it did have a desirable effect on VAS (visual analog scale). (R)

  • 36 individuals (ages: 21-65) with chronic non-pulsatile tinnitus participated in this randomized, triple-blind, placebo-controlled, crossover trial.
  • Patients with: (1) depressive and anxiety disorders and/or (2) hearing aids – were excluded from participation.
  • Participants received alprazolam (1.5 mg/day) vs. placebo.
  • Measures: Tinnitus Handicap Inventory (THI); Visual Analog Scale (VAS); tinnitus loudness.

What can we learn here? Alprazolam (1.5 mg/day) didn’t have a significant effect on THI or tinnitus loudness – but did significantly improve VAS score relative to the placebo. VAS improvement indicates that alprazolam may provide benefit (even if indirect) among persons with chronic tinnitus.

Vernon & Meikle (2003): “For patients whose tinnitus cannot be masked, oral administration of alprazolam may be an effective alternative, which should be done with knowledge and cooperation of the patient’s primary care physician.” (R)

  • It has been the authors’ experience that alprazolam can be an effective treatment for tinnitus in a large number of patients, with proper attention to tapering of the drug and with supervision provided by each patient’s physician.
  • It should be emphasized that the drug does NOT help everyone – there are some patients for whom alprazolam provides no significant benefit (e.g. observable change in tinnitus).
  • It was reported that in at least one patient alprazolam increased preexisting tinnitus.
  • For unclear reasons, some patients have found the generic forms of the drug (i.e. alprazolam) were NOT effective for them even though they achieved “excellent tinnitus relief” with brand name “Xanax.”

Huynh & Fields (1995): “There is insufficient evidence to support the use of alprazolam in the treatment of tinnitus.” (R)

  • The Johnson trial is the only study to date evaluating the therapeutic potential of alprazolam for the management of tinnitus – but this study has significant limitations.
  • Double-blind, controlled, crossover studies with adequate statistical power are needed to determine whether alprazolam is truly effective for tinnitus.
  • If efficacy is established, then additional studies are necessary to determine: duration of therapy; necessity of maintenance therapy; the role of “drug holidays;” appropriate dose tapering protocols; and which specific patients are likely to respond to alprazolam.

Note: This was a relatively pointless paper because it told most what they already knew at the time: there’s insufficient evidence to support using alprazolam for tinnitus. Instead it would’ve been smarter to conduct the research that was proposed.

Johnson et al. (1993): “Alprazolam is a drug that will provide therapeutic relief for some patients with tinnitus. Regulation of the prescribed dosage of alprazolam is important since individuals differ considerably in sensitivity to this medication.” (R)

  • Systematically tested the efficacy of alprazolam (0.25 mg or 0.5 mg) for the management of tinnitus.
  • Design: Prospective, placebo-controlled, double-blind.
  • Subjects: 40-adult patients with “constant tinnitus” who had experienced tinnitus for a minimum of 1-year.
  • Results: 17/20 patients in the experimental group and 19/20 in the placebo group completed the study.
    • Alprazolam users: 13/17 (76%) reported reduction in the loudness of tinnitus.
    • Placebo users: 1/19 (5%) reported a reduction in the loudness of tinnitus.

What can we learn here?

This study supports the idea that alprazolam (0.25-0.5 mg) is beneficial in reducing perceived loudness of tinnitus in a subset of chronic tinnitus sufferers.

Authors state that alprazolam should be used as an option when patients fail to benefit from: tinnitus masking; hearing aids; or other therapy.

Authors state that alprazolam should NOT be used for longer than 4-month intervals. After each 4-month interval, it should be gradually discontinued for at least 1 month before reinitiating treatment.

Interestingly, for some patients, tinnitus remains low for several weeks after alprazolam discontinuation before returning to its original level (this may be due to some sort of lingering neurochemical alteration/entrainment following alprazolam cessation).

Alprazolam as an adjunct for tinnitus (studies)…

Saberi et al. (2021): Combination of fluoxetine plus alprazolam was NOT significantly more effective than standalone fluoxetine in the treatment of chronic tinnitus. (R)

  • 147 patients with chronic tinnitus were divided into 3 groups: (1) fluoxetine; (2) fluoxetine + alprazolam; and (3) placebo.
  • Measures: Tinnitus Handicap Inventory (THI); Visual Analog Scale (VAS); Tinnitus Severity Index (TSI); Beck Anxiety Inventory (BAI); Beck Depression Inventory (BDI).
  • Results: Fluoxetine significantly reduced VAS, THI, BDI – but increased BAI (anxiety). Combination therapy (fluoxetine + alprazolam) significantly reduced VAS, THI, BAI, and BDI. None of the interventions reduced TSI (tinnitus severity index).
  • Conclusion: Both groups improved THI and VAS. Combination therapy was not significantly different from single-drug (fluoxetine) treatment.

What can we learn here?

Standalone fluoxetine was as effective as fluoxetine plus alprazolam on tinnitus handicap index (THI) and other measures like VAS and BDI (depression).

However, standalone fluoxetine seemingly increased BAI (anxiety) whereas the combination (fluoxetine plus alprazolam) reduced BAI (anxiety) – likely due to the presence of alprazolam (a potent anxiolytic).

Because many patients derive benefit from SSRIs for the treatment of psychological issues associated with tinnitus – it wasn’t a surprise that fluoxetine provided benefit.

Combination of fluoxetine plus alprazolam also provided equal benefit and reduced anxiety (a common problem for tinnitus sufferers) instead of increasing it (like standalone fluoxetine).

Lastly, since researchers did not independently evaluate alprazolam – it remains unclear as to how standalone alprazolam would compare to standalone fluoxetine for tinnitus management.

Shim et al. (2011): The results of the present study indicate that intratympanic dexamethasone (ITD) injection plus alprazolam (0.25 mg/day for 3 months) is the best treatment choice for subjective idiopathic tinnitus (SIT) within 3 months of development.

  • In most cases tinnitus onset is triggered by cochlear damage – it’s possible to eliminate the tinnitus while cochlear lesions are still reversible.
  • Researchers evaluated the therapeutic effects of various treatments on acute subjective idiopathic tinnitus (SIT) and investigated prognostic factors affecting treatment outcome.
  • 107 patients with SIT participated in a prospective, controlled, double-blind trial – and were assigned randomly into 3 groups: (1) oral alprazolam 0.25 mg for 3 months (N=32); (2) oral alprazolam 0.25 mg for 3 months + ITD 5 mg injections (N=35); and (3) oral alprazolam 0.25 mg for 3 months + ITD 5 mg injections + prostaglandin E1 10 mcg IV for 4 consecutive days.
  • Patients with tinnitus of non-cochlear origin such as somatic tinnitus and vascular tinnitus – were not included in this study. Tinnitus combined with SSNHL were also not included in this study.
  • Results: Improvement of Group 2 (alprazolam 0.25 mg for 3 months + ITD 5 mg injections) was significantly higher than that of Group 1 (alprazolam only).
    • There was no significant difference in improvement rate of Group 3 relative to the other groups.
    • Cure rates were significantly higher in Group 2 (25.8%) and Group 3 (20%) than Group 1 (9.8%).
    • There was a significant correlation between cure rate and duration of symptoms.

What can we learn here?

ITD injection (5 mg) plus alprazolam (0.25 mg/day for 3 months) is an effective intervention for patients with recent-onset (within 3 months) subjective idiopathic tinnitus.

That said, it remains unclear as to whether alprazolam provided any legitimate benefit – considering there was no placebo control.  Perhaps the significant benefit was explained mostly by ITD.

In the third group, perhaps the prostaglandin E1 injections offset or interfered with ITD to some extent – which is why improvement wasn’t as significant.

Results of this study should be interpreted with caution given limitations of short-term follow-up period (within 3 months) and relatively small group size.

There’s no evidence from this study to support the idea that alprazolam provides significant benefit in acute SIT.

Does the scientific literature support the use of alprazolam for tinnitus?

Alprazolam may: (1) reduce the perceived loudness of tinnitus and/or (2) treat secondary symptoms to tinnitus (e.g. anxiety, psychological distress, irritability) – such that it makes tinnitus easier to cope with for certain individuals.

Every trial/report in which alprazolam was evaluated as a standalone treatment for tinnitus noted that it generally provided some degree of benefit – even if indirect.

  • Jalali et al. (2009): Alprazolam failed to improve tinnitus handicap index (THI) and subjective tinnitus loudness – but it still significantly improved visual analog score.
  • Vernon & Meikle (2003): Based on clinical experience, alprazolam can be effective for tinnitus in a “large number of patients.”
  • Johnson et al. (1993): Tinnitus significantly reduced with alprazolam relative to placebo.

Because there are really only 2 trials of alprazolam for tinnitus and outcomes were mixed (one reported significant benefit vs. other reported no significant benefit except on visual analog scores) – and both are limited by sample size and/or design, the efficacy of alprazolam in tinnitus remains unclear.

Nevertheless, as was mentioned, preliminary data suggest that alprazolam provides some benefit to many tinnitus patients – even if indirect (e.g. reduction in tinnitus-induced anxiety).

And although (according to Vernon & Meikle) alprazolam is clinically effective for a large number of patients with tinnitus – not all patients find it beneficial.

A small percentage of patients experience a worsening of tinnitus from alprazolam – and others report zero change in tinnitus.

Alprazolam might also be useful as an adjunct treatment for tinnitus:

  • Intratympanic dexamethasone (ITD) plus alprazolam seems to be an effective treatment combination for recent-onset subjective idiopathic tinnitus (SIT) of cochlear origin.
  • Alprazolam combined with fluoxetine (SSRI) appears to reduce anxiety symptoms in tinnitus patients significantly more than standalone fluoxetine (which actually increased anxiety).

As of current, there is zero robust evidence to support the clinical recommendation of alprazolam as a treatment for tinnitus.

Additionally, there are significant concerns associated with using alprazolam for tinnitus such as: adverse events (e.g. psychomotor impairment, cognitive deficits, etc.), drug interactions, rapid tolerance onset, dependence, addiction/misuse potential, and withdrawal syndrome. (Read: Alprazolam & Cognition)

However, it’s important to acknowledge that there are ZERO medications approved by the FDA for the treatment of tinnitus – and some patients will require pharmacological intervention to cope with tinnitus (e.g. modulate tinnitus perception and/or manage the psychological impact of tinnitus).

Therefore, assuming alprazolam is properly and cautiously utilized under the supervision/guidance of a medical doctor – it could be a safe and effective intervention for a subset of tinnitus patients.

A paper by Kim et al. (2021) acknowledged that alprazolam is an off-label treatment for tinnitus (among many others). (R)

What is the proposed alprazolam dose regimen for tinnitus? (Vernon & Meikle)

Patients differ significantly regarding the dose that is effective for reducing tinnitus.

For this reason, it is recommended to initiate treatment with a “gradually increasing dose” regimen and with medical supervision.

Vernon & Meilke recommend the following regimen with a 6-week trial period: (R)

Weeks 1-2

0.5 mg alprazolam each evening before bedtime.

This dose is generally insufficient to relieve tinnitus, but allows patients to adapt to the drowsiness that occurs when alprazolam is first started.

(All patients should be warned about the drowsiness and should take precautions such as avoiding driving/heavy machinery, etc.).

This dose should be continued until the drowsiness subsides.

Weeks 3-4

0.5 mg alprazolam twice daily (morning & evening).

If dose reduces tinnitus sufficiently – patient continues this dose indefinitely under physician supervision.

Weeks 5-6

0.5 mg alprazolam thrice daily (morning, afternoon, evening).

If dose reduces tinnitus sufficiently – it is continued indefinitely under physician supervision.

No tinnitus relief (?)

If patients derive insufficient tinnitus relief from 0.5 mg alprazolam thrice daily (total dose of 1.5 mg) – then the drug should be discontinued with a gradual tapering schedule.

Tapering: 0.5 mg twice daily for 3 days, then 0.5 mg once daily for 3 days, then complete cessation.

(Sometimes even slower discontinuation is needed to avoid withdrawal symptoms.)

Ideal use of alprazolam in tinnitus management

Safety check

Patients receiving alprazolam for tinnitus should be screened to ensure that the medication is safe in accordance with: medical status, medical history, usage of other medications, and existing medical conditions.

Gradual titration (on/off)

Alprazolam should be gradually titrated on and off the drug to avoid serious adverse reactions and prevent severe withdrawal syndrome.

Lowest effective dose

Patients should use the lowest effective dose of alprazolam for the management of tinnitus to reduce the severities of side effects and to make withdrawal easier.

“As needed” (Maybe)

Some medical doctors recommend consistent twice daily dosing of alprazolam to build up tolerance to its initial drowsiness effect (such that the drowsiness subsides and danger of operating heavy machinery is minimized).

However, this isn’t always optimal due to tolerance onset (usually after weeks).

Certain individuals get better long-term results using “alprazolam” on an as-needed basis when tinnitus seems particularly loud or is causing significant anxiety.

“As needed” usage (assuming not frequent) may prevent alprazolam tolerance while maintaining its efficacy.

Adjunct to other strategies

Alprazolam should be used as an adjunct intervention with things like relaxation, noise masking, physical exercise, CBT (e.g. tinnitus-retraining therapy), dietary adjustments, etc.

(Relying solely on alprazolam for tinnitus relief may be a mistake).

Bridge to habituation (?)

Some individuals may find alprazolam useful when they initially develop tinnitus as a bridge to habituation.

In other words, alprazolam is used to calm the fight-or-flight response, reduce anxiety, and improve sleep – along with other interventions such that “habituation” is eventually achieved and sustained after alprazolam cessation.

Risks of using alprazolam for tinnitus

Anyone using alprazolam for the management of tinnitus should be cautioned about the potential risks before treatment.

Additionally, medical doctors should supervise/check in on patients to ensure: (1) tolerability; (2) efficacy; (3) dosing/administration compliance; (4) no interactions/contraindications (with other medications and medical conditions).

  • Addiction potential: Certain individuals may develop an addiction to alprazolam because it activates the mesolimbic reward pathway (via dopaminergic effects secondary to GABA-A modulation).
  • Dependence: Alprazolam has potential to cause physical and psychological dependence.
  • Tolerance: Studies suggest that tolerance onset associated with alprazolam is rapid – such that it is developed within days of regular administration. If tolerance is reached, tinnitus may reemerge due to GABA-A receptor downregulation or function changes.
  • Withdrawal syndrome: Withdrawal from alprazolam can be difficult if used regularly for a long-term. In some cases, patients may experience a worsening of perceived tinnitus loudness and distress in withdrawal – along with other reactions like anxiety, insomnia, rumination, etc.
  • Side effects: Cognitive impairment (e.g. memory deficits, attentional deficits, etc.), psychomotor impairment, fatigue, drowsiness/sleepiness, brain fog, sexual dysfunction, slurred speech, dizziness, balance problems, etc.
  • Contraindications: Alprazolam should not be used by individuals with certain medical conditions – as it may increase risk of complications or death.
  • Interactions: Alprazolam can interact with a variety of other substances that function as CNS inhibitors (e.g. alcohol, gabapentinoids, opioids, etc.).
  • Motor vehicle/machinery accidents (?): Alprazolam should NOT be used while operating a motor vehicle or heavy machinery – as it can significantly increase risk of accidents.
  • Worsening tinnitus (?): A small percentage of individuals may experience a worsening of tinnitus while taking alprazolam OR during alprazolam withdrawal. (This is rare but has been reported by physicians and patients.)

Alprazolam for tinnitus relief & reduction (anecdotes)

Below are various anecdotes paraphrased from individuals who reported deriving some benefit from alprazolam in the management of tinnitus.

The (1) magnitude of therapeutic effect(s); (2) sustainment of therapeutic effect(s); and (3) specific therapeutic effect(s) (e.g. reduced tinnitus perception, reduced anxiety secondary to tinnitus, or reduced tinnitus & resulting anxiety) – vary among users.

Keep in mind that there are many more anecdotes regarding alprazolam use for tinnitus than documented below – I merely picked some at random to document.

Alprazolam helped tinnitus (anecdotes)

  1. Anecdote #1: It helped my tinnitus for only the first week and then I developed hyperacusis from taking it.
  2. Anecdote #2: I was prescribed Xanax early on for anxiety related to tinnitus. I ended up using it mostly for sleep, which it really helped me with. Never took more than two 0.5 mg tabs a day.
  3. Anecdote #3: It’s very effective as a temporary measure when having a bad spike. The doc told me that 0.5 no more than twice a week is safe.
  4. Anecdote #4: Took alprazolam for the first time today – what a godsend. It cut my tinnitus by 80%.
  5. Anecdote #5: Was prescribed 0.5 mg 2x per day by GP for anxiety caused by tinnitus. I have to say that it does really help me. Takes the edge off and lowers the volume a couple of clicks for a few hours.
  6. Anecdote #6: I do use Xanax. It did help me get my anxiety under control and that helped my tinnitus indirectly.
  7. Anecdote #7: I take 0.5 mg of Xanax and it sometimes seems to help.
  8. Anecdote #8: I’ve tried 0.5 mg and it makes my T fade into the background a little more.
  9. Anecdote #9: I take a low therapeutic dose of Xanax every night and my life has not been destroyed and it’s been 2 years. I have moderate tinnitus. This drug has saved my life. I have no withdrawal symptoms if I miss my nightly dose.
  10. Anecdote #10: I take Xanax low dosage when I am having trouble coping with tinnitus. (Implying that it helps).
  11. Anecdote #11: All tinnitus and ear-related symptoms go away (ear tension, burning pain, etc.).
  12. Anecdote #12: Was suicidal due to extreme panic attacks (resulting from tinnitus) and alprazolam was a lifesaver. Never experienced withdrawal issues with benzodiazepines.
  13. Anecdote #13: At first Xanax seemed like magic and stopped tinnitus for hours – this effect lasted weeks but started to decline. Increased dose more (0.5 mg, b.i.d.) and reduced tinnitus again. Eventually the tinnitus reemerged though and became even worse in withdrawal than baseline.
  14. Anecdote #14: I had a tinnitus spike and nervous breakdown and everyone told me to take Xanax that I was prescribed (0.25 mg). Within 20 minutes I literally felt like a normal human being again for the first time in 10+ years.
  15. Anecdote #15: After taking alprazolam my tinnitus reduced by 70-80%.

Alprazolam did NOT help tinnitus (anecdotes)

Relative to the number of individuals reporting therapeutic benefit from alprazolam for tinnitus or symptoms secondary to tinnitus (e.g. panic/anxiety) – a smaller number of users report zero discernable benefit of using alprazolam for tinnitus.

  1. “I take two 0.5 mg tabs a day. Calms me down but does nothing for my tinnitus, good or bad.”
  2. “I have tried it a few times in the past 13 years and go no benefit from it.” (This individual also did NOT respond to other benzos like lorazepam & clonazepam).
  3. “Xanax didn’t really do much for me but I was on only ½ the lowest dose so it might have been too little.”

Can alprazolam cause tinnitus or worsen preexisting tinnitus?

Yes, but this is extremely rare. In fact, according to Dr. Stephen Nagler: “the incidence of alprazolam-induced tinnitus is even lower than the incidence of placebo-induced tinnitus.” (R)

Read: Can Alprazolam Cause Tinnitus & Hearing Loss?

It’s possible that some individuals develop tinnitus or experience an increase in tinnitus from alprazolam due to:

  • Neurochemistry at baseline
  • Paradoxical response to alprazolam (this is documented in literature)
  • Alterations in cerebral blood flow & inner ear biochemical processes
  • Interactions and/or contraindications (with other substances used or existing medical conditions)

In other cases, alprazolam may reduce auditory reflex thresholds to make individuals more susceptible to noise-induced hearing loss and subsequent tinnitus.

Alprazolam may also cause tinnitus onset or increase during alprazolam withdrawal.

In some cases, the tinnitus in withdrawal will be “somatic” (resulting from anxiety and/or tension) whereas in other cases the tinnitus may be due to rebound excitatory neurotransmission and stress hormones (possibly causing excitotoxicity, inflammation, oxidative stress, etc.).

Have you experienced tinnitus relief from alprazolam?

If you had tinnitus and/or hearing loss prior to taking alprazolam – have you found alprazolam helpful in reducing: perceived tinnitus loudness and/or anxiety-associated with tinnitus?

  • What dosage of alprazolam do you find most effective for tinnitus?
  • How often do you use alprazolam for tinnitus? (e.g. as needed, once daily, twice a week, etc.)
  • How long have you used alprazolam for tinnitus? (e.g. months, years, etc.)
  • If you take alprazolam regularly (e.g. daily) – has its therapeutic effect faded over time?
  • If you’ve stopped alprazolam, did you experience rebound tinnitus loudness or associated distress (e.g. anxiety)? (If you experienced worse tinnitus during alprazolam withdrawal – did it eventually stop?)
  • Do you take other medications or use substances that could affect tinnitus?
  • Do you find alprazolam most effective for: (A) perceived tinnitus loudness; (B) tinnitus-related psychological distress (e.g. anxiety, insomnia, fight-or-flight); or (C) tinnitus loudness AND tinnitus-related psychological distress.

My thoughts on alprazolam as a tinnitus treatment…

Overall I think that alprazolam can be a safe and effective intervention for some individuals with tinnitus if used cautiously with guidance from a medical doctor or psychiatrist.

If I were using alprazolam for tinnitus, I’d want to work with a psychiatrist simply because they’re usually better trained in managing titration (on/off) of benzodiazepines and are more knowledgeable about effective dosing strategies.

I’d probably also attempt to use alprazolam on an “as needed” basis due to the potential for rapid tolerance onset and subsequent reduced efficacy.

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