You’ve heard me talk about the impact of noise—for better and worse—on sleep. But recently I received several questions during my FaceBook Live Wake Up Wednesdays (7:30 am PST if you have not seen it yet) about tinnitus and sleep. Looking back, I have never written about it, so I decided to dive in and learn more.
What is tinnitus?
Tinnitus involves the perception of “phantom” sounds that aren’t coming from an external source. Often described as “ringing in the ears,” people with tinnitus can actually experience a wide variety of sounds, including:
- “White noise” sounds, akin to static
- Snippets of music
Whatever the specific sounds, these noises are only perceptible to the individual. Tinnitus noise can vary widely in volume. About 1 in every 4 people with tinnitus describe their sounds as loud.
Many of us experience tinnitus every once in a while. If you’re exposed to extremely loud noise or leave a noisy environment for a quiet one, you may notice a temporary buzzing or ringing in your ear. Maybe you’ve been near loud construction like a jackhammer, or stepped out of a loud action movie or music concert to a quiet lobby or street. (Be aware: even a single exposure to very loud noise can do damage to your hearing, and increase your risk for tinnitus.)
About 25-30 million Americans have tinnitus as a condition, and they experience these noises on a regular, most often daily, basis. About 40 percent of people with tinnitus hear tinnitus noise through 80 percent of their day. And for a smaller group of people—about 1 in 5—tinnitus is disruptive enough to significantly interfere with daily functioning, becoming disabling or nearly disabling.
Tinnitus becomes more common with age, in part because of age-related hearing loss. Among adults ages 65-84 years old, it’s estimated that about 27 percent have tinnitus.
What causes tinnitus?
There are several potential causes of tinnitus, including:
- Hearing loss (though not everyone with tinnitus has a hearing issue)
- Exposure to loud noise
- Ear disease
- Ear or sinus infections
- Ear, neck, and head injuries
- TMJ disorders
- Earwax build-up
- Hormonal imbalances in women
- Cardiovascular disease
- Thyroid disorders
- Some medications, including (but not limited to) antibiotics, antidepressants, diuretics, cancer medications, and very high doses of aspirin.
Hyperacusis is a different but related condition to tinnitus. People with hyperacusis have a high sensitivity to common, everyday environmental noise. In particular, sharp and high-pitched sounds are very difficult for people with hyperacusis to tolerate—sounds like the screeching of brakes, a baby crying or a dog barking, a sink full of dishes and silverware clanging. Many people with tinnitus also experience hyperacusis—but the two conditions don’t always go together.
Research shows that sleep disorders, tinnitus, and hyperacusis often occur together. In one study, 30 percent of people with tinnitus also had both a sleep disorder and hyperacusis.
How tinnitus affects sleep
People with tinnitus often have difficulty sleeping, and feel tired and fatigued during the day. They also appear to be significantly more likely to have sleep disorders than the general population. A study that examined the relationship between sleep problems and tinnitus found that 54 percent of people with tinnitus also had a sleep disorder.
According to research, people with tinnitus report several sleep problems, including:
- Having trouble falling asleep
- Not getting enough sleep
- Experiencing poor quality sleep
- Feeling less refreshed in the morning
There seems to be a two-way-street relationship between tinnitus and sleep problems. The symptoms of tinnitus can interfere with sleeping well—and poor sleep can make tinnitus more aggravating and difficult to manage effectively. In the same study that found a majority of people with tinnitus had a sleep disorder, the scientists also found that the presence of sleep disorders made tinnitus more disruptive.
Why is tinnitus so disruptive to sleep? Often, it’s because tinnitus sounds become more apparent at night, in a quiet bedroom. The noises of daily life can help minimize the aggravation and disruptiveness of tinnitus sounds. But if your bedroom is too quiet, you may perceive those sounds more strongly when you try to fall asleep—and not be able to drift off easily.
In addition to the tinnitus noises themselves, there are also other symptoms of tinnitus that may interfere with sleep, making it more difficult to fall asleep and stay asleep throughout the night. They include:
Stiffness, pain, and tension in the head, neck, and jaw. Physical pain or discomfort can be a major obstacle to sleep, affecting both sleep quality and sleep quantity.
Daytime fatigue. Daytime fatigue is one sign of a lack of high-quality sleep. Being tired during the day also can contribute to even worse sleep, by creating irregular sleep schedules and sleep-wake times.
Depression, anxiety, and irritability. Tinnitus can cause frustration and anxiety, and lead people to struggle with low mood. Stress and mood disorders are among the most common causes of insomnia and other sleep problems.
Anxiety can be a major factor
Both depression and anxiety occur frequently in people with tinnitus. A 2016 study found that among people with tinnitus, 45 percent will develop an anxiety disorder at some point in their lifetime.
Often, people with tinnitus can develop anxiety specifically about sleep, and their ability to fall asleep. This is a vicious cycle that frequently occurs in people who have trouble sleeping, regardless of the initial cause of their sleeplessness.
Imagine you’re settling in for a night’s rest. In your quiet bedroom, you tune right into those tinnitus noises—and you can’t shake your focus on them. You start to wonder about how you’ll ever fall asleep with these sounds in your ears. You think about the rest you’re missing out on because you’re not already asleep, and you wonder how you’ll have the energy to make it through your day.
Before long, you’re both mentally and physically stimulated in ways that make it even harder to relax and fall asleep. Like any other form of anxiety, stress about falling asleep creates mental arousal, bringing your brain to alertness. And it also creates physical arousal, raising heart rate and body temperature. This kind of anxiety can lead to behaviors that further undermine sleep, including:
- Sleeping late or at odd times during the day, leading you to an irregular sleep schedule
- Relying on alcohol as a sleep aid
- Scrolling through your smartphone or watching TV when you can’t sleep in the middle of the night
Pretty soon, you’re getting even less sleep—and you’re even more worried about it. Mindfulness is one of the best, most effective strategies for breaking this cycle. I’ve written before about the power of mindfulness in boosting sleep.
Emotional stress and anxiety also can interfere with how well people manage their tinnitus. Staying relaxed is one important way to minimize the disruptiveness of tinnitus.
Sleep apnea, hearing loss, and tinnitus are linked
There’s some pretty interesting science indicating that obstructive sleep apnea may be a cause of hearing loss, making the sleep disorder an indirect contributor to tinnitus.
A large 2014 study of almost 14,000 people found obstructive sleep apnea was linked to significantly higher rates of hearing impairment and hearing loss. Scientists think one reason for this involves changes in blood flow to the ear that result in inflammation. (We know that sleep apnea causes changes to circulation and weakens blood flow to some areas of the body, including the brain.) A related factor? People with sleep apnea are at greater risk for high blood pressure, and high blood pressure can exacerbate hearing loss, according to research.
It’s also possible that very loud snoring—a hallmark symptom of sleep apnea—can be loud enough to damage a sleeper’s hearing.
Research shows higher risks for sleep apnea and other sleep disturbances in people with tinnitus.
Ways to treat tinnitus and improve your sleep
There is not yet a cure for tinnitus, but scientists are studying the underlying causes of the condition and exploring potential avenues for treatment, including:
- Electrical and magnetic stimulation of the brain’s hearing centers
- Deep brain stimulation to calm neural activity associated with tinnitus
Many of the common treatments for tinnitus involve addressing anxiety and managing your response to the internal noise you hear. These treatment strategies can make tinnitus less frustrating and disruptive to live with—and also help you sleep better.
Avoid a too-quiet bedroom. People with tinnitus may find it easier to sleep in a less quiet bedroom and may benefit from white noise or other sleep-friendly sounds that help mask and minimize their tinnitus. To my patients who are looking to introduce soothing sounds to their sleep environment, I recommend the iHome Zenergy Sleep System, which combines relaxing sounds with aromatherapy and sleep-promoting light therapy.
Practice mindfulness meditation. I’ve written about the power of mindfulness mediation to reduce stress and improve sleep. A 2017 study found mindfulness meditation is also effective in helping people better manage tinnitus. Mindfulness meditation involves sitting comfortably, putting your attention on your natural breathing. When your mind wanders—to irritating tinnitus sounds, to worry about sleep, or wherever else it goes, gently return your attention to your breath. Start with a 5-minute session, and as you grow more comfortable with the practice, you can increase the time. You can practice mindfulness meditation anywhere, at any time of day—including in the shower!
Use other relaxation techniques. Tinnitus is understandably anxiety provoking, often a source of frustration and stress throughout the day and night. Reducing anxiety, and finding ways to relax, have benefits for both tinnitus and sleep. Relaxation exercises can reduce the aggravation of tinnitus, and make you more able to fall asleep. A few of the relaxation techniques my patients find most effective and easy to use are:
Deep breathing. Deliberate, relaxed breathing can help move the body into the slower breathing patterns that are associated with sleep.
I like the 4-7-8 breathing exercise:
- Inhale for 4 seconds
- Hold your breath for 7 seconds
- Exhale for 8 seconds
- Repeat several times
Progressive relaxation. An exercise of tensing and relaxing specific areas of the body can relieve physical tension and mental stress, and may help take the focus away from tinnitus noise. Start with your feet and work upward through the lower and upper body, to the shoulders, neck, and head.
Guided imagery. Engaging the senses in a soothing, comforting scene or journey can relax the body and the mind, and pull focus away from the irritating sounds of tinnitus. Whether you’re imagining yourself walking along the beach or along a peaceful wooded trail, be sure to include sound as part of your imagery.
Aromatherapy. Engaging your sense of smell with soothing, sleep-friendly scents may help reduce the stress and irritation of tinnitus and help you unwind to fall asleep with less difficulty. Lavender, jasmine, and vanilla are among the scents that promoting sleep.
Seek out cognitive-behavioral therapy. Cognitive-behavioral therapy, or CBT, involves working with a clinician (or independently, with a clinically-developed self-treatment program) to re-frame negative thoughts, emotions, and behaviors. CBT is effective with a wide range of physical and mental health conditions, including stress, anxiety, and depression. CBT is also highly effective in treating insomnia and other sleep problems. And research shows CBT can help improve the management of tinnitus.
Limit use of earplugs. Earplugs are important to use to protect your hearing when you’re likely to be exposed to loud noises. (Remember, exposure to loud sounds, and noise-induced hearing loss, are common causes of tinnitus, and may make tinnitus worse if you already have the condition.) But otherwise, people with tinnitus are advised not to wear earplugs, including for sleep. Earplugs reduce your ability to hear external noise and can make tinnitus more noticeable.
Using earplugs too frequently can lead to earwax buildup, another potential cause of tinnitus. When you do use earplugs, be sure they are clean (or new, if you’re using the disposable kind) with each and every use, to avoid exposing the ear canal to dirt and bacteria.
Don’t ignore ear pain. Pain or discomfort in your ear can be a sign of conditions associated with tinnitus, including ear infections and earwax buildup. These conditions, and the discomfort they cause, can also interfere with sleep. Whether your ear pain is sharp or dull, constant or intermittent, accompanied by itching or not, take these symptoms to your doctor.
Seek treatment for hearing problems. If you’re experiencing difficulty hearing, talk to your physician and seek help from an otolaryngologist (an ear, nose throat specialist) or an audiologist. In addition to addressing any underlying health issue and improving your quality of life, improving your hearing can make tinnitus less noticeable and less bothersome, during the day and at night when you’re trying to sleep.
Another thing that tinnitus and sleep problems share? A tendency among people to brush them off, and try to “tough it out,” rather than addressing their conditions. It’s not worth it, to your health or your quality of life. If you’re having trouble sleeping and you have symptoms that sound like tinnitus, talk with your doctor about both, so you can sleep better—and feel better—soon.
Michael J. Breus, Ph.D., DABSM
The Sleep Doctor™