The Merits and Flaws of Tinnitus Retraining Therapy

As a tinnitus specialist, I often hear from patients wondering if Tinnitus Retraining Therapy (TRT) is the right solution for them. While TRT has helped many people, its effectiveness is often debated, and not all tinnitus cases respond the same way. In this review, I’ll take a critical look at TRT—what it involves, how much it costs, whether it truly works, and the biggest flaw in its approach.

Here, you'll find answers to:

• What is Tinnitus Retraining Therapy (TRT)?
• What is the #1 flaw with TRT?
• How much does TRT cost?
• Does TRT work?
• Online Tinnitus Retraining Therapy + Medical Rehabilitation

What is Tinnitus Retraining Therapy?

Tinnitus Retraining Therapy (TRT) is a structured tinnitus treatment that combines educational counseling with sound therapy to help individuals habituate to their tinnitus. Developed in the 1990s by audiologist Pawel Jastreboff, PhD, TRT is based on the Neurophysiological Model of Tinnitus, which concerns how tinnitus triggers the fight-or-flight response.

Many people report lasting relief with TRT, but does it actually work better than other treatments? A 2025 meta-analysis (a combination of multiple studies) showed that TRT shows no significant advantage over standard sound therapy, hearing aids, or educational counseling. This raises serious questions about its effectiveness.

If TRT works no better than standard therapy, why is it still widely recommended? Below, I’ll break down how TRT works, what’s missing from the TRT approach, its biggest flaws, and whether it’s worth the cost.

TL;DR: TRT Is An Outdated Model of Care

TRT helps some people, but studies show it’s no better than basic sound masking. Its core flaw? It ignores the real cause of severe tinnitus: central nervous system hypersensitivity. NeuroMed’s modern approach combines sound therapy with medical treatment, leading to faster, more effective results for most patients (up to 90%).

The Biggest Flaw in Tinnitus Retraining Therapy

The fundamental flaw in TRT is that it presents an outdated and incomplete understanding of what causes tinnitus, particularly in severe tinnitus cases. Current research shows that severe tinnitus is driven by a migraine-associated hypersensitivity of the hearing nerves and related brain structures.

Over the past five years, we’ve published numerous academic papers demonstrating that tinnitus is a form of atypical migraine, a sensory processing disorder driven by nerve inflammation, increased brain excitation, and sensory hypersensitivity. This migraine-driven hypersensitivity then causes central sensitization, where sensory threshold levels are lowered, creating a persistent state of easily triggered loud tinnitus.

Here's an outline of the new model of severe tinnitus:

Stage in Tinnitus Development	Description
Tinnitus Initiation	Inner ear damage (noise damage, infection, ototoxic medications, aging, COVID, etc) leads to hearing loss. The auditory nerves become hyperactive. This is registered in the brain as a phantom sound but it is not yet LOUD.
Neurogenic Inflammation	Nerve inflammation, triggered by environmental or internal stressors, enhances sensory signaling, intensifying the perceived loudness of tinnitus. This is also known as the migraine reaction.
Central Sensitization	The recurrent inflammatory events trigger a process known as central sensitization (brain sensitivity). This is permanent reset of sensory thresholds results in auditory hypersensitivity and easily triggered loud tinnitus.
Fear Activation	The fear center of the brain (the limbic system) is activated as a side effect of the loud tinnitus. Tinnitus annoyance increases and hypervigilance and sympathetic drive increases.
Increased Attention	Loud ringing increases brain attention (its “salience”). The salience network includes brain regions that determine how much attention we pay to sensory signals. It now becomes hard to ignore.
Neural Network Formation	Stable neural networks establish, making the ringing a permanent fixture. It starts to be encoded in the default mode network, the part of our brain that defines the “new normal”.
Neural Network Strengthening	Continued cycles of neurogenic inflammation (atypical migraine) focus strengthen neural networks, potentially triggering migraines and creating a vicious cycle.
Clinical Significance	Clinically significant tinnitus emerges, impacting quality of life and emotional health. This kind of tinnitus responds poorly to sound-based approaches. Medical intervention is required for relief.

When an Outdated Model Fails Patients

TRT frames tinnitus loudness as a product of negative emotions, an outdated explanation that ignores current research. We now understand that loudness is primarily driven by neuroinflammation and sensitization, not simply by attitudes or emotional reactions.

This misrepresentation creates a gaslighting effect, where patients are told their tinnitus is loud because of their emotional state. When they don't improve, the blame shifts to them for not following the approach correctly, rather than recognizing the underlying neurological mechanisms at play.

The fundamental flaw in TRT is its failure to account for atypical migraine and central sensitization—key drivers of tinnitus loudness. Without addressing these root causes, patients are left managing symptoms rather than treating the source of their tinnitus. Effective relief requires targeted medical interventions that extend beyond sound-based therapies.

What happens in Tinnitus Therapy Treatment?

In essence, tinnitus therapy treatment via TRT gives patients a graduate-level course on tinnitus and the auditory system, delivers a masking device and sound therapy education, and then provides emotional support over a period of months to years. 

In traditional TRT, the first visit is REALLY long, sometimes lasting up to 6 hours. In fact, it's usually broken up into several days. There are four things on the initial visit agenda:

• Initial Interview and Testing: This is where you explain in detail what your tinnitus is like, followed by extensive testing of middle ear problems, hearing loss in one or both ears, and specifics about your tinnitus frequency.
• Medical History: This step makes sure that treatable medical conditions related to tinnitus are ruled out. This part is sometimes performed by an ENT doctor. Special attention is given to screen for hyperacusis, a condition where loud noises cause pain and discomfort.
• Tinnitus Counseling: This is where you get your degree in tinnitus science. Basically, you are taught the basic principles of the neurophysiological model of tinnitus.
• Sound Therapy: The final step in the initial TRT is how to use sound therapy. Here you’re offered various sound therapy options, instructed to avoid silence, and encouraged not to completely cover their tinnitus. It usually includes the sale of either hearing aids for tinnitus or ear-level masking devices (looks like a hearing aid).

Next you have a series of followup visits where your audiologist reinforces the model and discusses your progress. The typical cadence of treatment is to follow up at 1, 3, 6, 12, and sometimes 18 months. Some packages include more frequent visits, but in general, the minimum length of the program is 6-12 months. 

What is “Tinnitus Counseling” in TRT?

The primary goal of tinnitus counseling in TRT is to demystify tinnitus. When people know what’s going on with their tinnitus, it gives them a sense of empowerment. They are taught the Neurophysiological Model of Tinnitus (see Addendum below). 

Here is a list of key concepts taught in the first TRT session. This is modified from a handout from a well known TRT protocol that’s given to patients after the first visit [1].

TRT Concept	Concept Explanation
The goal of TRT is to change your mind.	TRT helps your brain to reclassify the tinnitus signal from “dangerous” to “unimportant”. This is not a conscious process; you can't force your mind to do it. However, if you understand the goal and use sound therapy properly, it will stop tinnitus from activating your fear center.
Tinnitus is not the same thing as hearing loss.	While the two usually go together, tinnitus does not mean you are actively losing hearing. Tinnitus is not a warning sign that you’re losing hearing. Basically, don’t freak out about your hearing.
The brain makes tinnitus loud and annoying, not your ear.	Loudness and annoyance are related to the strength of negative feelings you have regarding the tinnitus signal. The emotional part of your brain and your autonomic nervous system are what makes tinnitus annoying, not your ear.
Don’t focus on what you can’t fix.	The hearing is gone and the tinnitus is here to stay. What you can do is change the way your brain reacts to it. Don’t focus on the features of the tinnitus sound, it doesn’t determine your outcome.
The tinnitus signal is weak and neutral.	It doesn’t change from good days to bad days. So if you could measure the auditory system activity on a good day or a bad day, the signal is the EXACT SAME. What changes are the other parts of your brain (the fear center).
Tinnitus is a phantom auditory perception.	The hearing center recognizes the hyperactive nerve signal coming from the cochlea and recognizes it as a sound. The problem is that we can’t control it. When we lose control, the fear center freaks out.
The brain has the ability to rewire and change.	We can rewire the brain to filter out the tinnitus sound and reclassify it from “threat” to “not important”. This is habituation, or ‘passive extinction’. All we can do is understand the goal and use sound therapy religiously.

Here are four additional concepts taught in the first session and reinforced in later TRT sessions [1]:

Selective Perception in Tinnitus

This describes the subconscious filtering of sound signals enhances different or important information while filtering out neutral details. Routine activities are often ignored once deemed nonsignificant, illustrating habituation.

• Imagine the feeling of your socks on your feet. They’ve been on your feet all day. The sensory signals coming from your feet to your brain have not stopped or changed. When you pay attention to it, you feel the socks, but in one paragraph, your brain will have forgotten about it again. Many people have tinnitus and for them, it’s like socks on their feet; they don’t notice it until asked to pay attention to it. 

Sensory Contrast in Tinnitus

Perception of a signal is influenced not only by its physical intensity but also by its strength relative to the surrounding activity. Tinnitus loudness is heightened in quiet settings due to sensory contrast. Sensory contrast explains why background noise is so important.

• Imagine a candle in a pitch dark room. In the darkness, the candle is super bright. However, if you open the blinds and turn on the light, the candle seems not bright at all. The number of photons reaching your eye from the candle light has not changed. It’s the same with tinnitus when its quiet. With nothing else going on, the tinnitus signal seems louder, even though the auditory nerve signally rate hasn’t changed. With background noise, the tinnitus sound becomes insignificant.

Prioritization in Tinnitus

Subconscious processes can override conscious decisions, prioritizing important or threatening signals. This phenomenon is evident in situations where seemingly insignificant sounds can evoke strong reactions, highlighting the influence of subconscious meaning on attention and response.

• Imagine you are alone at night and you hear the creaking of a floorboard down the hall. Is someone breaking in? Your fear center kicks in and now you're listening intently for any tiny hint of another sound. This hypervigilance happens with tinnitus. Once the sound is perceived as a threat, it gets “prioritized” so now your mind finds the tinnitus sound subconsciously, often even searching for it to see if it's still there. 

Habituation in Tinnitus

Habituation in TRT is when your brain simply stops paying attention to the tinnitus signal. Per above, it’s not something that you do actively. It’s something that happens passively when you use sound therapy properly. Essentially, the sound of your tinnitus becomes like the feeling of your socks on your feet. You can hear the tinnitus sound if you listen, but most of the day, your brain ignores it.

Psychoeducation in Tinnitus Retraining Therapy: Not All Bad

This is great information, and I agree with many parts of it. However, the model is incomplete—it’s missing key concepts, including emerging insights into the link between tinnitus and migraine. TRT captures only half of the picture, leaving critical neurological factors unaddressed.

What is sound therapy in TRT?

For the brain to habituate, it has to still hear the sound signal. This is a key difference between TRT sound therapy and tinnitus masking. Here are some key principles on TRT's sound therapy component:

Sound Therapy Component	Explanation
The Mixing Point	Sound therapy files should be set to the point at which you can just barely hear your tinnitus. This is called the “mixing point”. TRT participants are counseled not to mask tinnitus above this point.
Noise-enriched Environment	TRT is also big on silence avoidance and always practicing environmental sound enrichment. This helps reduce tinnitus perception.
Sound Files	Most TRT programs use simple white noise as the type of masking sound. Masking is designed to effectively suppress the tinnitus sound, but in TRT, you want people to hear their tinnitus sound so they can habituate to it.
Daily Duration	Most programs call for using sound therapy for a minimum of 4 hours a day, daily. Clinical data supports this. In a trial comparing 1,3, and 5 hours mixing point masking, the 5 hour group had statistically significant improvements in tinnitus symptoms over the other groups [2].

Tinnitus Maskers and Hearing Aids in TRT

There is no standard for tinnitus masking or sound stimulation in TRT. Here are the most common options:

Device Option	Description
Tinnitus Masking Devices	Most of the time, people are offered ear-level white noise generators that look like a hearing aid. This may be appropriate for someone with normal hearing or only mild hearing loss. They can go behind the ear or in the ear canal.
Hearing Aids	These are dispensed to people who have tinnitus and moderate to severe hearing loss. However, in these cases, those with hearing loss are still instructed to use some other source of external sounds.
Combination Hearing Aids	Many hearing aids can be programmed to generate white noise at the mixing point. This way you get both amplification and masking while wearing hearing aids. Using a hearing aid allows you to accurately produce mixing point matching.
External Sound Machines	This is the use of conventional sound generators. Most options these days include settings where you can choose the color of noise (ie pink noise or brown noise) or select from nature sounds (rain, ocean, etc.). Here the masking noise is coming from external sound, rather than sound into the ear canal.

One criticism of most TRT programs is that they'll try to sell you an expensive hearing aid-type device. Theoretically, there is no reason why the sound generated for TRT can't be from external noise generators, headphones, earbuds, or other sources of background sounds.

How much does Tinnitus Retraining Therapy cost?

TRT costs anywhere from $3,000-$7,000. The cost depends on several factors, such as the inclusion of an ear-level sound generator and the number of sessions included in the program. Even online TRT can be expensive. For instance, one online TRT clinic offers a 6-month program for $5000. The high price is nearly always related to the embedded sale of an overpriced ear-level device.

Does Tinnitus Retraining Therapy work?

Yes, TRT can help reduce tinnitus distress, but it’s not more effective than other treatments. Research, including large clinical trials, shows that TRT provides relief for some people [3], but it does not outperform standard sound-based therapies like tinnitus masking [4].

One of the largest and most well-designed studies on TRT—the Tinnitus Retraining Therapy Trial—put this claim to the test. In this trial, researchers compared TRT to standard tinnitus masking programs [4]. The results? Both approaches led to improvement, but TRT showed no significant advantage over standard therapy.

In other words, while TRT can be effective, it is not superior to other well-established tinnitus treatments. And if it works no better than other treatments, why invest the time and money? TRT is expensive, time-consuming, and requires months to years of commitment.

What is the difference between TRT and CBT for tinnitus?

There are similarities between TRT and Cognitive Behavioral Therapy (CBT). The American Tinnitus Association characterizes TRT as “A treatment regimen that combines the use of traditional CBT counseling with supplemental sound masking to habituate patients to tinnitus”.

I think this is inaccurate. The Tinnitus Counseling of TRT is very technical, like a graduate level class. The focus is very narrow and does not come close to the full spectrum of psychological tools available in CBT for tinnitus.

CBT tools may be more effective than the ones used in TRT. In one clinical trial, a form of CBT called Acceptance and Commitment Therapy (ACT) was compared to standard TRT. At 6 months, tinnitus severity (measured by the Tinnitus Handicap Inventory) resulted in better improvements in the CBT group than the TRT group (reduction 54.5% vs. 20%) [6]. This illustrates both the power of CBT techniques or deficiencies in TRT tinnitus counseling.

What is online Tinnitus Retraining Therapy?

Modified Tinnitus Retraining Therapy (MTRT) is a modern adaptation of TRT, designed to retain its most effective components while making the process shorter, more affordable, and accessible. Online TRT is one form of MTRT, offering the same counseling benefits in a convenient virtual format. Similarly, app-based TRT programs have demonstrated comparable success to conventional methods, providing a flexible, user-friendly option for patients [5].

Another approach to MTRT involves intensive programs where patients complete all tinnitus counseling over a focused 7-day period. These programs often include multidisciplinary care, allowing patients to work closely with a team of healthcare professionals. By streamlining the process and leveraging modern technology, MTRT expands access to effective tinnitus management. 

Tinnitus Retraining Therapy Online + Medical Rehabilitation

At NeuroMed, we provide modified Tinnitus Retraining Therapy (TRT) online—but with a major advantage: our program is integrated with medical treatment to address the neurological imbalances that drive loud tinnitus.

NeuroMed = Online Tinnitus Retraining Therapy + Medical Rehabilitation

Traditional TRT includes counseling and sound therapy, but lacks medical intervention. Our 20-week telemedicine program includes 15 or more telehealth visits, where patients work directly with medical professionals who can prescribe medications and oversee a personalized medical plan of action to target the underlying causes of tinnitus, making the included components of TRT more effective.

What Makes NeuroMed’s Online Tinnitus Therapy Treatment Different?

We provide all the components of traditional Tinnitus Retraining Therapy online, but nest this intervention within a comprehensive, medically-supervised rehabilitation program that goes beyond sound therapy and counseling alone. Our approach includes:

• App-based CBT – Retraining the brain’s response to tinnitus
• Customized sound therapy – Algorithm-based to match each patient’s unique tinnitus profile
• Prescription medication therapy – Addressing the brain chemistry that drives tinnitus loudness
• Nutraceuticals – Targeting neuroinflammation and oxidative stress
• Dietary interventions – Supporting brain and nervous system health
• Sleep optimization – Improving restorative sleep to reduce tinnitus severity
• Mindfulness therapy – Helping regulate the brain’s response to tinnitus
• Motivational interviewing – Coaching patients through the recovery process
• Lifestyle medicine – Addressing overall health factors that influence tinnitus
• Psychoeducation – TRT-style education to help patients understand their condition

Faster Results, Better Outcomes

NeuroMed’s cutting-edge, medically integrated tinnitus program is achieving 85-90% success rates—far surpassing traditional TRT. Why choose our medical model of online tinnitus retraining therapy?

✔ Shorter Treatment Timeline – Achieve relief in months, not years
✔ Superior Outcomes – Scientifically designed for faster, more effective results
✔ Comprehensive Care – Medical interventions + CBT + sound therapy + lifestyle medicine
✔ Expert Team – Work directly with specialists who understand tinnitus at its core
✔ Unparalleled Support – 15+ telehealth visits in 20 weeks for precision medicine approach
✔ Cutting-Edge Science – The latest breakthroughs in tinnitus & neuroscience

Conclusion: Online TRT + Medical Rehabilitation = Success

All tinnitus specialists owe a debt of gratitude to Jastreboff for his pioneering work on managing tinnitus. The clinical protocol that emerged from his research shows positive outcomes. However, there are three critical questions that illustrate where TRT falls short:

• Does TRT work better than other forms of tinnitus therapy? No.
• If it yields the same outcomes, but is more expensive and time consuming, is it worth it? No.
• Are expensive hearing aids or masking devices necessary to treat tinnitus? No.

Ultimately, the key flaw with TRT is that it does not include the most important discoveries about what drives tinnitus perception, namely migraine-associated sensory hypersensitivity. Without addressing the fundamental causes of tinnitus, results will always fail to reach the kind of high success rates we are seeing at NeuroMed, 85-90%.  

If you would like to explore a more effective, science-backed approach with NeuroMed's medically-based online tinnitus retraining therapy, schedule a FREE consultation today to learn how we can help you take control of your tinnitus.

The Neurophysiological Model of Tinnitus

TRT: Frequently Asked Questions

TRT References

[1] Gold SL, Formby C, Scherer RW. The TRT Counseling Protocol as Implemented in the TRT Trial. Am J Audiol. 2021 Mar 10;30(1):1-15. doi: 10.1044/2020_AJA-20-00024.

[2] Jin IK, Choi SJ, Ku M, Sim Y, Lee T. The Impact of Daily Hours of Sound Therapy on Tinnitus Relief for People With Chronic Tinnitus: A Randomized Controlled Study. J Speech Lang Hear Res. 2022 Aug 17;65(8):3079-3099. 

[3] Han M, Yang X, Lv J. Efficacy of TRT in the treatment of tinnitus: A meta-analysis and systematic review. Am J Otolaryngol. 2021 Nov-Dec;42(6):103151.

[4] Suh MW, Park MK, Kim Y, Kim YH. The Treatment Outcome of Smart Device-Based TRT: Prospective Cohort Study. JMIR Mhealth Uhealth. 2023 Jan 12;11:e38986.

[5] TRT Trial Research Group; Scherer RW, Formby C. Effect of TRT vs Standard of Care on Tinnitus-Related Quality of Life: A Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg. 2019 Jul 1;145(7):597-608.

[6] Westin VZ, Schulin M, Hesser H, Karlsson M, Noe RZ, Olofsson U, Stalby M, Wisung G, Andersson G. Acceptance and commitment therapy versus tinnitus retraining therapy in the treatment of tinnitus: a randomised controlled trial. Behav Res Ther. 2011 Nov;49(11):737-47.