Tinnitus After COVID and Long COVID
The connection between long COVID and tinnitus is strong. While most studies report the prevalence of tinnitus in long COVID patients to be between 20-40%, a recent study of 990 people with long COVID showed that up to 73% report tinnitus as a chronic symptom [1]. The numbers for tinnitus after COVID and COVID vaccine tinnitus are likely even higher, as formal criteria for a long COVD diagnosis are strict.
Here I review the topic of tinnitus after COVID, including long COVID and issues with the COVID vaccine:
- What is long COVID?
- What are the common long COVID symptoms?
- What causes long COVID?
- Why does COVID cause tinnitus?
- COVID vaccine tinnitus connection?
- How can you treat long COVID-related tinnitus?
Intro to Long COVID and Tinnitus
The connection between COVID and tinnitus has become a topic of increasing interest as more people report tinnitus after COVID infection or COVID vaccine tinnitus. Understanding the underlying mechanisms behind COVID-related tinnitus is critical to developing effective treatments and addressing this growing issue.
Researchers are discovering that nerve hyper-excitability during periods of brain inflammation, such as with viral infections or trauma, may cause the development or worsening of tinnitus [2]. Since acute COVID infection involves a period of brain inflammation, this may be the reason why COVID-related tinnitus (or COVID vaccine tinnitus) is so prevalent.
What is Long COVID?
Not long after the first waves of COVID infections had passed, doctors began to note that certain patients were having prolonged symptoms. We now refer to this collection of lingering symptoms as long COVID.
There are several other names used in the research literature for long COVID, including long-haul COVID, chronic COVID, post-COVID syndrome (PCS), or post-acute sequelae of SARS CoV-2 infection (PASC).
What is the definition of Long COVID?
The World Health Organization (WHO) drafted a consensus statement that defines long COVID (which they call “post COVID condition”). Here are the WHO diagnostic criteria:
- A history of SARS-CoV-2 infection, with
- Post-infection symptoms that persist for three or more months, and
- Where these symptoms last for at least 2 months, and
- Where these symptoms cannot be explained by another diagnosis [3].
Estimates of the prevalence of long COVID are evolving, but the Centers for Disease Control (CDC) estimates that 1 in 5 people infected with the SARS-CoV-2 virus will develop long COVID [4].
Tinnitus After COVID Is Likely Underestimated
The WHO/CDC definition of long COVID requires that people have symptoms for multiple months after getting infected. However, this may underestimate the problem. A meta-analysis pooling global data from 1.6 million patients showed that 43% of people infected with COVID-19 had prolonged symptoms lasting greater than 28 days [5].
Tinnitus after COVID infection or COVID vaccines tinnitus is likely underestimated, as some studies fail to capture the full scope of cases, focusing on a limited set of symptoms. Many individuals may not immediately connect tinnitus to their COVID experience, leading to underreporting and an inaccurate reflection of its true prevalence.
Is Long COVID a Disability?
The Department of Health and Human Services (HHS) has designated long COVID as a disability under the Americans with Disabilities Act (ADA) if it substantially limits major life activities [5].
Furthermore, health insurance reimbursement for long COVID conditions is also now possible, as the International Classification of Diseases (ICD-10) created the U09.9 code for “Post-COVID conditions, unspecified” as a billable code. This is important as it formally recognizes long COVID as a bona fide medical condition.
How common is long COVID?
Long COVID prevalence appears to be associated with the degree of neuroinflammation or severity from the original infection. For instance, in one meta-analysis of 10,945 cases of severe COVID-19 cases, approximately 64% developed a long COVID diagnosis [7]. However, in cases of asymptomatic COVID-19 infection, prolonged symptoms are much more rare, with an approximate 80% reduced risk of long COVID [8].
The fact that long COVID is much more common with the severity of the infection demonstrates the strong link between neuroinflammation and the development of COVID tinnitus, which will be discussed further below.
What are the common long COVID symptoms?
Long COVID can affect many different systems in the body. Here are some of the most common symptoms, grouped by bodily system and estimated prevalence (Table 1):
Table 1: Long COVID symptoms by system with estimated prevalence [9-12].
| System | Symptom |
| General | Fatigue (23-53%) |
| Malaise (20%) | |
| Joint or Muscle Pain (10-32%) | |
| Respiratory | Shortness of breath (14-26%) |
| Difficulty breathing (14-35%) | |
| Cough (5-40%) | |
| Cardiovascular | Chest tightness (48%) |
| Palpitations (5-44%) | |
| Gastrointestinal | Diarrhea (3-21%) |
| Abdominal pain (4-10%) | |
| Loss of appetite (6-14%) | |
| Neurologic | Cognitive impairment (9-50%) |
| Headache (5-33%) | |
| Impaired memory (14-19%) | |
| Ear, Nose | Dizziness/imbalance (4-60%) |
| Tinnitus (10-30%) | |
| Decreased sense of smell (6-36%) | |
| Psychological | Anxiety (8-24%) |
| Depression (7-23%) | |
| Post-traumatic stress (15-18%) |
This list is not exhaustive, as people also can experience problems in their immune system, kidneys, skin, and other areas. Long COVID that affects the heart and lungs can be particularly serious, requiring specialist care with a cardiologist or pulmonologist.
Brain Fog, ADHD, And Tinnitus
It's interesting that brain fog and tinnitus are often seen together in long COVID. We're now learning that brain fog is essentially the same clinical entity as inattentive-type ADHD. We expect to do more research in this area soon.
What causes long COVID?
The cause of long COVID is a matter currently being debated. Some are now framing long COVID as being a form of chronic pain syndrome. For instance, in long COVID, chronic pain, fatigue, headache, and cognitive impairment are among the most common symptoms [12].
This constellation of symptoms is very similar to those seen in other chronic multi-symptom conditions, such as migraine, fibromyalgia, chronic fatigue syndrome, ADHD, and post-concussion syndrome.
Long COVID and Central Sensitization
The common mechanism that long COVID and similar chronic conditions share is “central sensitization”. This process is involved in an atypical form of migraine where patients may not experience headaches, but rather a number of symptoms including dizziness, tinnitus, mental fogginess, blurring of vision, neck stiffness, head or ear pressure, among others. There is increasing consensus that long COVID is a form of “central sensitization syndrome” and it closely follows an atypical migraine pattern [13], [14].
Central sensitization is also seen in the setting of prolonged neuroinflammation. It describes a neurological process characterized by heightened sensitivity in the central nervous system which leads to an exaggerated reaction to stimuli, creating a self-sustaining cycle. This cycle results in a hypersensitive nervous system that amplifies signals and responds excessively to stimuli that would not typically be perceived as painful or bothersome.
As central sensitization advances, it leads to persistent adverse symptoms. Beyond physical effects like pain, vertigo, or tinnitus, individuals may experience cognitive and emotional shifts, including problems like “brain fog”, memory issues, and mood disturbances.
Stress and emotional states, such as anxiety and catastrophizing, significantly contribute to reinforcing the neuroplastic changes associated with central sensitization. Therefore, when treating central sensitization syndromes, addressing stress and regulating mood becomes crucial.
In addition, sleep disturbance and diet have major effects on central sensitization and persistence of symptoms. Improving sleep and adjusting the diet is critical in correcting the underlying central sensitization.
Are long COVID and tinnitus related?
Long COVID and tinnitus are strongly related, with estimates of the prevalence of long COVID-related tinnitus varying between 30% and 73% [1]. In fact, tinnitus as a symptom of long COVID is underestimated because researchers look for new symptoms, not necessarily worsening of existing symptoms. The same thing is true when it concerns COVID vaccine tinnitus.
To illustrate this point, in a survey of people who had tinnitus before the pandemic, 40% reported that their tinnitus was worse after being infected with COVID-19 [15].
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Why does COVID cause tinnitus?
There are several possible explanations for why COVID-19 infection might cause tinnitus. The initial injury to the hearing organ (the cochlea) is similar to other viral infections that affect the ear.
Inflammatory molecules called cytokines are significantly elevated in COVID-19 infection (called a “cytokine storm”). These elevated levels of cytokines may impact synaptic plasticity and contribute to auditory disorders linked to neuroinflammation.
Specific to COVID-19 infections, the SARS-CoV-2 spike protein has been shown to interact with certain receptors in the cochlea, showing that the inner ear is directly vulnerable to COVID-19 infection [16].
Central Sensitization and Tinnitus After Covid
Following the initial impact from infection, the progression toward chronic tinnitus or exacerbation of existing tinnitus is more likely attributed to central sensitization-related processes.
As noted above, central sensitization is heightened by influences from the emotional and stress-related regions of the brain, sleep, and diet. When these factors coincide with tinnitus, they reinforce the formation of new neural pathways that affect tinnitus severity.
Central sensitization increases the brain’s attention to the tinnitus, which increases the perception of tinnitus. The activation of migraine in these patients can lead to the development of cochlear migraine, a form of migraine that can cause de novo tinnitus or lead to increased loudness of pre-existing tinnitus.
Can the COVID vaccine cause tinnitus?
All vaccinations cause a certain level of inflammation, which is a natural part of how they work. Vaccines stimulate the immune system, allowing your body to recognize and fight off potential threats. However, this inflammation can sometimes trigger neuroinflammation, which may, in turn, provoke tinnitus.
Any inflammatory event in the brain has the potential to set off central sensitization, where the brain’s sensory thresholds are lowered. This means that sensations like pain, headaches, vertigo, and tinnitus can become more intense or frequent. This is common not only after vaccinations but also following events like concussions, migraines, or brain surgeries. Over time, prolonged inflammation leads to central sensitization, amplifying the perception of these symptoms.
COVID Vaccine Tinnitus Data
Since the vaccines were of a new type for COVID-19, there was some concern about their effect on tinnitus. As of September 14, 2021, the Vaccine Adverse Events Reporting System (VAERS) has documented 12,247 cases of post-vaccination tinnitus related to the coronavirus vaccine [17].
However, when put in the context of large populations, the reported cases of new onset of tinnitus after COVID vaccine is very low (less than 0.5%) [18]. In fact, these rates are lower than other commonly administered vaccines, such as the influenza vaccine. Nevertheless, this is looking only at new onset tinnitus COVID vaccine cases.
Underestimation of COVID Vaccine Tinnitus
The issue with this data is that it doesn’t seem to align with what we’re seeing in practice, a tinnitus COVID vaccine link. Our clinic primarily treats severe tinnitus cases, and within this group, we frequently hear reports of louder tinnitus after COVID vaccine administration. We suspect there may be political factors influencing the reported numbers, but we’re focused on the real-world experiences of our patients.
Will tinnitus from COVID vaccine go away?
As mentioned earlier, the most likely explanation for how COVID vaccines cause tinnitus is through central sensitization and the related atypical migraine process. These conditions are treatable with a multimodal treatment approach that combines medical therapy to manage ongoing brain inflammation and promote neuroplasticity. This is exactly what the Tinnitus Rehabilitation program at NeuroMed does.
Can active COVID cause hearing loss?
New onset hearing loss is commonly linked to viral infections. There is growing literature on the association between “sudden sensorineural hearing loss” (when hearing loss is sudden) and COVID infections. In one study of over 3700 people infected with COVID, between 5.1-6.4% responded that they experienced hearing loss 3 months or more after infection [10].
Some patients experience difficulty with word understanding in long COVID. This likely occurs because of the brain fog that long COVID causes, which decreases the brain’s ability to concentrate, especially in noisy environments. As noted above, this may be related to an ADHD-type process in the brain.
When people do have hearing loss with COVID, it’s frequently accompanied by tinnitus as well. In a case series of patients with COVID-related hearing loss, 61% also developed tinnitus [19].
Does long COVID cause vertigo?
Long COVID commonly comes with balance disorders, including vertigo. This correlation is expected, given the similarity in the tissues of the inner ear organs that are responsible for balance and for hearing.
A meta-analysis of long COVID symptoms found that vertigo, dizziness, or balance disorders were present in 27-42% of patients [10]. In another survey, 60% reported having either vertigo or dizziness as a symptom and 25% reported having both vertigo/dizziness and tinnitus together [1].
A likely cause of dizziness and vertigo in patients with long COVID is the activation of the migraine process. In this atypical form of migraine, patients may never experience headaches and the only manifestation of the migraine may be vertigo. This condition (termed “vestibular migraine”) may become chronic due to other factors such as stress, poor sleep, diet, visual motion stimulation, etc.
How can you treat long COVID-related tinnitus?
By viewing tinnitus and COVID-related symptoms as part of central sensitization, new avenues for treatment become possible for achieving sustained relief from tinnitus. The “biopsychosocial” approach to treating central sensitization conditions involves addressing the interconnected influences of biological, psychological, and social factors on an individual's health.
- Bio: Interventions may target neuroinflammation, pain pathways, and other physiological aspects. Treating sleep problems and following a diet low in specific molecules that trigger and maintain central sensitization.
- Psycho: Addressing stress, anxiety, and mood regulation is crucial, as emotional states significantly impact central sensitization.
- Social: Understanding the patient's environment, support systems, and lifestyle factors is essential for comprehensive care.
This holistic approach recognizes that effective management requires a combination of medical, psychological, and social interventions tailored to the individual's specific condition and circumstances.
How do you treat Long COVID Tinnitus?
When the biopsychosocial approach is applied to tinnitus, several strategies become apparent. Here are some commonly recommended interventions, along with their rationale, as they fit into the biopsychosocial model (Table 2).
Table 2. Elements of the biopsychosocial model applied to treatments for long COVID-related tinnitus.
| Intervention | Description and Rationale |
| Bio-Nutraceuticals | Certain nutraceuticals are very helpful in calming the brain inflammation associated with long COVID. They can also aid in promoting synaptic plasticity and regulating neurotransmitters. |
| Bio-Pharmaceuticals | Pharmaceutical medications like nortriptyline or topiramate (Topamax) may be employed to restore a balance in neurotransmitters, facilitating positive neuroplastic changes and alleviating tinnitus. |
| Bio- Tinnitus Masking | Sound therapy is a standard intervention for tinnitus. If you give your brain a chance to rest from the constant presence of tinnitus, new healthy neural networks have a chance of being created. |
| Bio- Exercise | Exercise helps with central sensitization by reducing nervous system hypersensitivity and promoting neuroplastic changes that contribute to alleviating chronic symptoms. |
| Bio- Diet Changes | A neuroprotective diet should be adopted in long COVID. You can reduce neuroinflammation with anti-inflammatory foods while minimizing processed foods, trans fats, and added sugars. The diet includes elimination of certain neurotransmitters that are contained in some foods. |
| Psycho- CBT | Cognitive behavioral therapy (CBT) for tinnitus involves identifying and modifying maladaptive thought patterns, developing coping strategies, and reducing catastrophizing behavior. |
| Psycho- Mindfulness | Practicing mindfulness can play a pivotal role in reducing tinnitus severity by specifically targeting the stress input from brain regions associated with tinnitus generation. |
| Psycho- Sleep Hygiene | Prioritizing sleep hygiene is essential for reducing long-COVID related tinnitus, as it supports neurological well-being and may alleviate symptom severity over time. |
| Social- Coaching | Coaching aids in tinnitus treatment by providing support, motivation, and guidance, addressing not only the physical aspects of the condition but also the emotional and social realms. |
The best approach is to combine these various elements and tailor them to an individual’s personal needs. This multimodal approach, combining pharmacologic, physical, and holistic interventions, enhances the chances of success in long COVID tinnitus recovery by addressing the diverse factors that contribute to its pathology.
Summary: You Can Treat Tinnitus After COVID
Tinnitus after COVID begins with initial inflammation, but it is the process of central sensitization that solidifies these symptoms into a chronic state. By comprehending the role of central sensitization in the establishment of long COVID symptoms, new treatment strategies become available.
In my practice and at NeuroMed, we use a multimodal strategy incorporating pharmacologic, physical, and natural approaches. This offers the most promising chances of success in addressing the complex nature of long COVID tinnitus.
Schedule a FREE consultation to discuss your symptoms and receive a personalized treatment plan tailored to your needs.
Long COVID and Tinnitus: FAQs
Can having COVID affect your ears?
Yes. COVID can affect the inner ear through inflammation, vascular changes, or direct viral entry into cochlear cells. This can lead to symptoms like tinnitus, vertigo, and hearing loss, especially in patients with long COVID or migraine sensitivity.
Can COVID cause hearing loss and tinnitus?
Absolutely. COVID-19 has been linked to sudden sensorineural hearing loss and worsening of existing tinnitus. The virus may directly affect the cochlea or indirectly trigger neuroinflammation and central sensitization, leading to long-term auditory symptoms.
Can long COVID cause ear problems?
Yes. Long COVID (the presence of lingering symptoms long after the active infection has passed), frequently involves ear-related symptoms such as tinnitus, ear pressure, dizziness, and even hearing loss. These are often tied to a migraine-like central sensitization process triggered by neuroinflammation following infection.
How long does tinnitus last with COVID?
Tinnitus may resolve in some individuals after a few weeks, but for others it can persist for months or become chronic. Long-lasting tinnitus is often a sign of central sensitization, which requires targeted treatment beyond time alone.
Is tinnitus a common side effect of the COVID vaccine?
While clinical studies report low rates of new-onset tinnitus after vaccination (<0.5%), real-world reports suggest it may be underrecognized, especially among those with pre-existing tinnitus. Post-vaccine tinnitus is most likely due to a temporary inflammatory response that can trigger central sensitization in vulnerable individuals.
Can COVID-19 cause dizziness and ringing in the ears?
Yes. COVID-19 can affect both hearing and balance. Dizziness and tinnitus are common in long COVID and may occur even without severe initial illness. These symptoms often reflect activation of the migraine system and central sensitization in the brain.
How long does a COVID ear last?
Ear symptoms from COVID—like tinnitus or ear pressure—can last weeks to months, and in some cases become chronic. If the symptoms are due to central sensitization, they can persist unless treated through a multimodal program targeting inflammation, brain plasticity, and sensory hypersensitivity.
How do you get rid of COVID tinnitus?
COVID-related tinnitus is best treated by addressing the root causes: brain inflammation and central sensitization. This involves calming neuroinflammation, improving sleep, and using nutraceuticals or medications that support healthy brain plasticity. A multimodal approach, like the one used at NeuroMed, includes sound therapy, dietary changes, CBT, and migraine treatment protocols to lower the volume and distress of tinnitus.
How do you treat COVID ringing in the ears?
Treatment should address both the neuroinflammation and the altered brain wiring responsible for persistent ringing. This includes migraine medications, anti-inflammatory nutraceuticals, sound therapy, dietary changes, and CBT. NeuroMed’s integrated program uses these tools to promote recovery.
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