Tinnitus and hyperacusis: how they are linked

Two different experiences

Tinnitus is hearing a sound that does not come from outside you. The NHS describes it as ringing, buzzing, whooshing, humming, hissing or throbbing, in one or both ears or in the head. It may come and go, or be there all the time.

Hyperacusis is when everyday sounds seem much louder than they should, and can sometimes be painful. Jingling coins, a barking dog or a vacuum cleaner can feel hard to bear. The American Speech-Language-Hearing Association (ASHA) describes it as discomfort, physical or emotional, from sounds most people find acceptable.

So tinnitus is a sound you hear when there is none, and hyperacusis is a reaction to sounds that are really there. They are different, but they are closely linked.

How often do they occur together?

Quite often, although the exact figures vary between studies and depend on who is being asked. A 2021 study by Refat and colleagues summarised the research this way:

• About 80 to 90% of people with hyperacusis also have tinnitus.
• About 30 to 50% of people with tinnitus also have hyperacusis.

A large Swedish study of more than 3,600 adults (Cederroth et al., 2020) found that people with hyperacusis were about three and a half times more likely to have tinnitus. The link was strongest in severe tinnitus, where as many as 80% of people also reported hyperacusis. Many of these figures come from self-reported symptoms or from clinic patients, so treat them as a rough guide rather than an exact count.

Why might they be linked?

Nobody knows for certain yet, but one leading idea is called central gain. Think of the volume control in your hearing system. When the ear sends less signal to the brain, for example after noise damage, the brain may turn its own volume up to compensate. A review by Auerbach and colleagues (2014) describes this as a possible mechanism behind both conditions.

If that is right, the extra “volume” might produce a sound of its own (tinnitus) and also make ordinary sounds feel too loud (hyperacusis). This is still a hypothesis. The researchers stress that several processes are probably involved, and it does not explain every case. Emotions matter too: the NHS notes that stress can make tinnitus worse, and ASHA lists anxiety and depression among the conditions often seen alongside both.

How treatment overlaps

Because the two conditions are so closely tied, many of the same approaches are used for both. They are often assessed together, and one plan can address both.

Sound therapy is a shared starting point. The NHS advises people with tinnitus not to sit in total silence, and suggests sound therapy for hyperacusis to get used to everyday sounds again.

Cognitive behavioural therapy (CBT) helps with the worry, avoidance and tension that can build up around both. In a 2014 randomised trial of 60 people with hyperacusis, Jüris and colleagues found CBT improved sound tolerance compared with a waiting list, with results largely lasting a year later.

Tinnitus retraining therapy (TRT) combines counselling with sound therapy. ASHA notes that its general principles may also be used for hyperacusis. The NHS says it is unclear whether TRT works for everyone.

Earplugs can backfire. The NHS warns that wearing earplugs all the time could make you more sensitive to noise, and advises people with tinnitus to avoid total silence. Short-term use in very noisy places may help. See our guide to earplugs and hyperacusis.

When to see a doctor

Most tinnitus is not a sign of anything serious, but some symptoms need checking quickly. Based on NHS and NICE guidance:

• Go to A&E or call 999 if tinnitus comes with sudden hearing loss, weakness in your face or a spinning feeling (vertigo), or follows a head injury.
• Ask for an urgent GP appointment if your tinnitus beats in time with your pulse (pulsatile tinnitus), or if you have sudden hearing loss in one or both ears.
• See a GP if tinnitus is in one ear only and does not go away, if it is getting worse or affecting sleep and mood, or if everyday noise feels too loud or painful.

A GP can check for simple causes such as earwax or an ear infection and refer you on. To learn more about the assessment, see how hyperacusis is diagnosed, or read our overview of hyperacusis treatment.