What is Reactive Tinnitus?

Reactive tinnitus is a subtype of tinnitus marked by unusual sensitivity to everyday sounds, often causing spikes in tinnitus intensity. Unlike typical tinnitus, which may worsen mainly with exposure to loud noises (like concerts or machinery), reactive tinnitus can be triggered by moderate or even mild sounds—such as running water, the hum of an air conditioner, or background noise in a café.

Is Reactive Tinnitus a Recognized Condition?

As of now, reactive tinnitus has not been formally recognized in the scientific literature, despite being widely discussed in tinnitus communities. This lack of formal recognition, however, does not diminish the very real impact it has on those affected. It is my hope that this article helps to address this deficiency and sheds light on this distressing problem.

Defining Reactive Tinnitus

Given that there is no current consensus in the medical community, I propose the following clinical definition for reactive tinnitus:

“Reactive tinnitus is a subtype of tinnitus characterized by an abnormal increase in tinnitus loudness, intensity, or character in response to specific auditory triggers.”

To aid in recognizing reactive tinnitus, I propose the following diagnostic criteria. While not all criteria must be present, individuals with reactive tinnitus may exhibit one or more of the following features:

1. Distinct Auditory Triggers: In reactive tinnitus, the intensity of tinnitus specifically escalates in response to particular trigger sounds, rather than general noise. These triggers are often low or moderate-level sounds that are continuous, rather than sudden or loud noises.
2. Immediate Reaction Pattern: In this pattern, individuals with reactive tinnitus experience an immediate escalation in tinnitus intensity as soon as they are exposed to a specific trigger sound. In these cases, the tinnitus intensity generally subsides soon after the sound is removed.
3. Cumulative Impact Pattern: In this pattern, exposure to trigger sounds throughout the day creates a cumulative “winding” effect, where tinnitus intensity progressively worsens with each encounter. Many report that sleep acts as a reset, providing relief from the accumulated effects of the day's triggers. Others sometimes report that sound exposure from the previous day can lead to a spike.
4. Prolonged Reaction Pattern: In this pattern, people with reactive tinnitus experience a prolonged reaction to sound. Following sound exposure, the tinnitus can remain heightened for an extended period, lasting from several hours to days before gradually returning to baseline. This elevated state may be progressive, leading to an increasingly persistent intensity level.
5. Functional Impact: Reactive tinnitus can lead to considerable functional impact, often resulting in avoidance behaviors, heightened anxiety, or hearing protection overuse to guard against trigger sounds.
6. Possible Dysacusis: In some people, distorted auditory perception (dysacusis) may accompany reactive tinnitus, including symptoms like echoing, warbling, or a metallic sound quality in response to specific frequencies or tones.
7. Distinct from Hyperacusis: Although hyperacusis may also be present, reactive tinnitus refers to a change in tinnitus intensity or character in response to sound vs. an increase in perceived loudness or sound sensitivity.

This clinical definition and diagnostic criteria for reactive tinnitus may help pave the way for improved recognition, targeted interventions, and a better understanding of this condition.

Common Sound Triggers

For individuals with reactive tinnitus, even soft background sounds can lead to spikes. Common triggers include:

• Everyday Environmental Sounds: Running water, air conditioning, refrigerator hums, fans, wind
• Household Appliances: Vacuum cleaner, dishwasher, washing machine, microwave, blender
• Digital and Electronic Sounds: Smartphone notifications, computer alerts, electronic device sounds, microwave beeps, Bluetooth speakers, video call chimes
• Background Noise in Public Places: Restaurant chatter, shopping mall noise, gym music, public transportation sounds, airplanes, and helicopters
• Traffic and Urban Noise: Car engines, roadwork, construction machinery, motorcycle revving, honking, sirens
• Music and Television: Moderate volume music, television, radio, movie theater sounds
• Social Gatherings: Group conversations, laughter, clinking dishes, crowded events
• Office and Workplace Sounds: Printers, copiers, typing sounds, HVAC systems, coffee machines
• Nature Sounds: Birdsong, wind rustling in trees, rainfall, ocean waves, thunderstorms
• Mechanical and Industrial Devices: Elevators, escalators, factory machinery, power tools
• High-Pitched or Repetitive Sounds: Alarm clocks, phone ringing, high-pitched beeps, electronic buzzing sounds
• Children’s Noises: Crying, shouting, playful screams, toy sounds
• Ambient Sounds in Quiet Spaces: Library murmurs, quiet breathing, background whispers
• Personal Care and Grooming Devices: Hairdryers, electric shavers, electric toothbrushes
• Transportation Noise: Airplane engines, train sounds, subway announcements
• Kitchen and Cooking Sounds: Clinking pots and pans, sizzling on the stove, chopping sounds

Immediate, Delayed, and Prolonged Reactions

Reactive tinnitus is characterized by variable reaction patterns, each presenting unique challenges.

Some individuals experience an immediate reaction to specific sounds, with tinnitus intensity spiking as soon as they encounter a trigger. Once the sound is removed, their tinnitus may return to baseline, but the response can still be distressing.

Others endure a cumulative impact or “winding” effect. With repeated or prolonged exposure to trigger sounds, their tinnitus gradually worsens throughout the day, creating a buildup that results in an increasingly intense reaction over time. Sleep can often serve as a reset to this pattern, but for others, a spike can be caused by the previous day's sound exposure.

• Sophia: “It feels like each sound just piles on top of the last. By the end of the day, even small noises are unbearable. Sleep helps bring it back down—until it starts all over again.”

For many, the reaction is prolonged, with spikes lasting hours to days, creating an exhausting cycle that disrupts daily life. Even after the sound stops, tinnitus often remains heightened, reflecting a delayed response that lingers beyond the initial exposure.

• Liam: “Just a few minutes of noise exposure can keep my tinnitus elevated for hours. After a recent family gathering, my ears were still ringing into that evening. It’s exhausting.”

These accounts capture the complex and unpredictable nature of reactive tinnitus, where responses to sound are not only intense but also variable in their duration and impact, creating a constant state of instability.

Functional Impact

Reactive tinnitus can create a substantial functional impact, often leading to avoidance behaviors, heightened anxiety, and a reliance on hearing protection to guard against triggering sounds. These responses can trap individuals in a cycle of increased sensitivity, isolation, and mental strain.

Avoidance Behaviors: Social Isolation and Withdrawal

To prevent tinnitus spikes, many people with reactive tinnitus withdraw from social activities and avoid environments that might expose them to triggering sounds. This avoidance can lead to a sense of isolation and disconnect from friends, family, and normal social life.

• Emily: “I stopped going to family gatherings because the background noise just leaves my ears ringing for hours. It's lonely, but I feel like I have no choice.”
• Mark: “Even small get-togethers have become overwhelming. I’ve pulled back from a lot of social activities because I’m constantly worried about the noise levels.”

Heightened Anxiety: Fear of Permanent Spikes

For those with reactive tinnitus, the anxiety around potential spikes can be intense, with a persistent fear that a spike could become permanent. This heightened anxiety creates a state of constant stress and hypervigilance, as individuals worry that even minor sounds might worsen their tinnitus indefinitely.

• Grace: “The fear that each spike might last forever keeps me on edge. I can’t relax because any sound might make it worse for days or even longer.”
• Daniel: “I live in constant fear that the next loud noise will make my tinnitus unbearable for good. It’s exhausting to be this on guard all the time.”

This increased anxiety can then create a feedback loop on tinnitus severity and functional impact. Again, we see how devastating the instability of reactive tinnitus can be.

Hearing Protection Overuse

To prevent spikes, many people with reactive tinnitus turn to earplugs or noise-canceling headphones. This can often do more harm than good, as over-relying on hearing protection can worsen sound sensitivity over time through a process called “central gain”. This is where the brain becomes more sensitive and amplifies everything, since it is not getting outside sound.

As the ears adapt to lower sound exposure, everyday noises become increasingly intense and uncomfortable when hearing protection is removed, creating a vicious cycle of dependency. Also, wearing ear plugs reduces outside every day masking sounds and this tends to make tinnitus more noticeable.

• Ben: “I’ve gotten so used to wearing earplugs that everything sounds too loud when I don’t use them. It feels like a trap—I need the protection, but it’s making me more sensitive.”
• Tom: “At first, I only wore earplugs in loud places. Now, I use them almost all the time. The problem is, my tinnitus spikes whenever I take them out, so I feel stuck.”

Note: While overuse of hearing protection can lead to additional problems, it’s important not to be critical of those who rely on it. Using hearing protection is a actually a practical survival strategy and makes sense when the medical community is offering no viable alternative.

Together, these behaviors—avoidance, heightened anxiety, and hearing protection overuse—can reinforce each other, deepening the functional impact of reactive tinnitus on daily life.

What is Dysacusis?

Dysacusis, the perception of distorted sounds, frequently accompanies reactive tinnitus and can be one of the most distressing aspects of the condition. In addition to the increased tinnitus intensity, individuals with dysacusis experience sounds as altered or abnormal, which adds a layer of disorientation and discomfort. People with reactive tinnitus may perceive sounds as muffled, metallic, echoing, or warbled—closely mirroring the auditory distortion experienced in dysacusis.

• Olivia: “My tinnitus doesn’t just spike with sound—it changes how I hear things. Voices and music sound warbled or off-pitch, like they’re coming through a broken speaker.”
• Samantha: “Sounds don’t just hit once and go away; they echo, bouncing around in my head long after the noise stops, which can be overwhelming and exhausting.”

The experience of dysacusis adds to the overall burden of reactive tinnitus, intensifying both the auditory and emotional challenges of the condition.

Reactive Tinnitus vs. Hyperacusis

In reactive tinnitus, while individuals may experience some sound sensitivity, their primary concern is an increase in tinnitus intensity following exposure to sounds rather than an increase in the perceived loudness of those sounds. This focus on the post-exposure spike in tinnitus intensity differentiates reactive tinnitus from hyperacusis, where the main symptom is discomfort or pain due to sound itself.

• James: “Sounds don’t bother me by themselves—it’s the way they make my tinnitus spike afterward that’s hard to handle.”

This distinction helps clarify the unique challenges faced by those with reactive tinnitus, focusing on managing tinnitus intensity rather than sound sensitivity.

Distinct from Misophonia

Misophonia is characterized by a strong emotional reaction—often irritation, anger, or even rage—to specific sounds typically generated by people, like chewing, tapping, or certain voices. Reactive tinnitus, on the other hand, is a physiological response where everyday sounds increase the perceived intensity of tinnitus, making it seem louder or more intrusive.

In misophonia, the reaction is emotional, and the triggers are generally more selective, limited to human related sounds. Reactive tinnitus, however, involves an actual increase in tinnitus intensity and can be triggered by a broader range of sounds, with an emotional response that differs from the intense feelings seen in misophonia.

What Causes Reactive Tinnitus?

With so little known about the condition, it is hard to say what causes reactive tinnitus, but there are three major theories that help to explain what is going on. Each theory offers a different perspective on the underlying mechanisms and may provide insights into potential approaches for managing the condition.

The Central Sensitization Theory

The Central Sensitization (CS) theory suggests that, similar to chronic pain or migraine, reactive tinnitus may worsen progressively due to an increased sensitivity within the central nervous system. In the CS theory, the nervous system amplifies auditory signals, leading to an exaggerated response to even low or moderate volume sounds [1]. This hypersensitivity makes the hearing pathways increasingly reactive.

A key component of CS is the wind-up phenomenon, where repeated stimulation causes bigger reaction from the brain.  With each stimulus, brain cells (neurons) become more responsive, eventually reaching a peak of hyperactivity.

This is precisely what we see in reactive tinnitus, where low or moderate sounds encountered throughout the day create a “winding” effect, progressively worsening the tinnitus reactivity with each incremental sound stimulus.

Reactive tinnitus shares features with chronic pain and migraine, such as exaggerated brain responses to sensory input. In both migraine and tinnitus, the brain regions processing these stimuli undergo changes, often influenced by neuroinflammation and other processes.

These changes increase the excitability of nerve connections (hypersensitivity), making the system prone to heightened, prolonged responses to sensory inputs. In the case of reactive tinnitus, this could manifest as exaggerated responses or sustained spikes in tinnitus intensity that persist beyond the initial sound stimulus.

The Kindling Theory

The concept of kindling, first explored in epilepsy research, refers to the progressive development of seizures due to repeated, low-level stimulation that, on its own, wouldn’t trigger a seizure. The term is now used to describe the features of a number of different conditions, including tinnitus and migraine.

In kindling, brief, low-intensity electrical stimuli applied repeatedly to certain brain regions eventually lead to heightened brain cell reactivity and, in some cases, seizures. Studies on audiogenic seizures—seizures triggered by sound—illustrate that repeated exposure to noise can induce seizure activity in sound-sensitive animals.

A kindling-like mechanism might occur in the brain centers for hearing (primary auditory cortex) in reactive tinnitus. Repeated sound exposure may lead to increased sensitivity, much like kindling in epilepsy.

This has been shown to be true in animal models of tinnitus. In these studies, repeated stimulation of the hearing nerves causes significant brain cell changes, including increased coordinated activity and changes of the auditory centers of the brain. This may explain why individuals with reactive tinnitus experience sustained spikes in response to sound exposure.

Neuroinflammation also plays a role in kindling. Studies indicate that inflammation markers increase susceptibility to sound-triggered seizures [2]. This aligns with migraine research, where neuroinflammation intensifies the brain’s response to stimuli. For reactive tinnitus, inflammation may amplify neural reactivity to sound, like how it heightens responses in migraines and seizures.

The Migraine Theory: A Unified Perspective

Reactive tinnitus may best be explained as an atypical form of migraine, arising from overlapping mechanisms like neurogenic inflammation, central sensitization, and kindling. This theory brings together elements from Central Sensitization (CS) and Kindling theories, suggesting reactive tinnitus as a migraine-like hypersensitivity response to auditory stimuli.

1. Central Sensitization

Central sensitization (CS) is foundational to migraine pathology, amplifying sensory input and causing heightened responses to light, sound, and other stimuli. In reactive tinnitus, a similar CS mechanism likely explains why even low and moderate sounds cause an exaggerated tinnitus response. The “winding” effect observed in reactive tinnitus aligns with the wind-up phenomenon in migraine, where repeated exposure to sensory input (i.e. sound) progressively intensifies nerve cell responses. This shared process of sensory amplification places reactive tinnitus within the broader theory and mechanism of migraine hypersensitivity.

2. Kindling

Kindling is also integral to migraine research, explaining how repeated, low-level stimuli can create a state of increased brain reactivity. In migraine, kindling leads to accumulating sensitivity where minor, repeated triggers eventually provoke a full migraine episode. In reactive tinnitus, this effect may cause the auditory system to become more reactive over time. The kindling theory provides a model for understanding the progressive worsening of tinnitus symptoms in response to cumulative sound exposure, framing reactive tinnitus as a form of atypical migraine.

3. Neuroinflammation

Neuroinflammation plays a key role in both migraine and reactive tinnitus, heightening neural excitability and sensory sensitivity. In migraine, inflammatory molecules amplify pain and sensory response, a process mirrored in reactive tinnitus, where inflammation likely heightens sensitivity in the brain's auditory centers. Inflammatory factors contribute to nerve cell hyperexcitability in both conditions, linking migraine and reactive tinnitus through a common neurological mechanism.

4. Sensory Hypersensitivity

Reactive tinnitus and migraines both show heightened sensory hypersensitivity, reacting strongly to triggers like light, sound, motion, heat, smells, atmospheric pressure, and diet. This sensitivity stems from shared neurological pathways involved in sensory processing, particularly the trigeminal (responsible for head and facial sensation) and auditory pathways. This overlapping hypersensitivity supports the classification of reactive tinnitus within the migraine spectrum, as both conditions exhibit amplified responses to environmental stimuli.

5. Sensory Dysregulation and Thalamocortical Dysrhythmia

Sensory dysregulation in reactive tinnitus and migraine likely involves disruptions in multi-sensory integration within the thalamus, a part of the brain that processes and integrates sensory input. Severe tinnitus and migraine have both been linked to thalamocortical dysrhythmia—a state of abnormal brain wave activity between the thalamus and cortex that causes distorted perception. In reactive tinnitus, this abnormal pattern may contribute both to symptom escalation (through the removal of the normal inhibitory influence of the thalamus) and to distorted sound perception (dysacusis), mirroring the sensory distortions often experienced in migraine.

6. Episodic Nature and Time Course

The episodic pattern of reactive tinnitus, with symptoms intensifying in response to cumulative sound exposure, parallels the episodic nature of migraines. Just as migraine build ups in response to environmental triggers and then settles, reactive tinnitus exhibits a time course that increases with exposure and diminishes over time. Both conditions show similar responsiveness to triggers like stress, sleep disturbances, and environmental factors, reinforcing the link between reactive tinnitus and migraine.

7. Responsiveness to Migraine-Based Treatments

The effectiveness of migraine-targeted treatments in reducing symptoms of reactive tinnitus and hyperacusis supports this theory. For instance, in a clinical trial at our university, we achieved a significant reduction in hyperacusis (sound sensitivity) symptoms in 88% of study participants using a migraine-related treatment protocol (the same that is used at NeuroMed) [3]. This suggests that approaches addressing neuroinflammation and hypersensitivity in migraine may also be beneficial for reactive tinnitus.

Viewing reactive tinnitus as a manifestation of atypical migraine offers a unified model that incorporates all the central features of the condition. This framework positions reactive tinnitus as a form of sensory hypersensitivity driven by migraine-related mechanisms, providing a basis for targeted treatments that address its neurogenic origins.

Reactive Tinnitus Treatment

Managing reactive tinnitus requires a unique and carefully structured approach that differs from typical tinnitus treatments. Jumping directly into sound therapy can often worsen symptoms, so the initial focus should be on stabilizing the underlying atypical migraine process that drives sound reactivity and symptom instability.

Multimodal Treatment at NeuroMed

For nearly all forms of tinnitus, a multimodal plan offers the best path to improvement. At NeuroMed, this typically includes:

• Pharmaceuticals: Medications that balance brain excitation and inhibition can help reduce reactive tinnitus.
• Nutraceuticals: Supplements supporting brain health and reducing inflammation play a crucial role.
• Lifestyle Modifications: Adjustments in diet, exercise, sleep, and stress management contribute to symptom stabilization.
• Cognitive Behavioral Therapy (CBT): CBT techniques to manage anxiety and stress associated with reactive tinnitus.

Sound-Based Treatment for Reactive Tinnitus

Once reactivity stabilizes, sound-based treatments can be gradually introduced to build tolerance:

• Graded Sound Exposure: Start with low-intensity, non-distressing sounds in a controlled environment, gradually increasing exposure as comfort grows. Progress to real-world sounds over time.
• Sound Introduction with Hearing Protection: Use hearing protection with progressively lower levels (e.g., 25 dB to 20 dB) to reduce dependence in controlled settings, then move toward natural listening environments at a comfortable pace.
• Broadband Noise Desensitization: Begin with low-level broadband sounds or customized sound therapy files in a safe space, slowly raising the volume. Track progress in a journal, combining exposure with relaxation techniques to support tolerance.

The Rehabilitation Approach at NeuroMed

At NeuroMed, we embrace a rehabilitation approach. Our program involves a medical intervention combined with structured sessions designed to build skills, resilience, and tolerance over time. This comprehensive, step-by-step strategy empowers patients with the tools they need for long-term management and symptom relief. Consistency is essential in managing reactive tinnitus, as progress is often gradual. Moving slowly and staying within comfort limits are crucial for lasting success.

The Need for More Reactive Tinnitus Research

New insights into the role of migraines in tinnitus have opened up exciting and effective treatment possibilities, like those used in NeuroMed’s protocols. However, reactive tinnitus remains incompletely understood, with its unique challenges often overlooked in both research and clinical settings.

Here are some key questions that I believe future research should address on this topic:

1. What is the prevalence of reactive tinnitus?
2. What are the common co-morbidities of reactive tinnitus, i.e. hyperacusis, central sensitization, anxiety, or chronic pain?
3. How does reactive tinnitus correlate with tinnitus severity?
4. What changes occur in the brain in response to triggers for reactive tinnitus?
5. Do specific causes of tinnitus (e.g., noise-induced, age-related) predispose individuals to developing reactive tinnitus?
6. Are there particular sound frequencies or types that most frequently exacerbate reactive tinnitus and do these correlate with the person's audiogram?
7. Does reactive tinnitus progress or change over time, and if so, what factors influence its trajectory?
8. Is reactive tinnitus more common with certain tinnitus frequencies, such as low-pitched vs. high-pitched tinnitus?

Addressing these questions through comprehensive research could pave the way for more accurate diagnoses, effective management strategies, and a deeper understanding of reactive tinnitus as a distinct condition.

Conclusion: Reactive Tinnitus is Treatable!

Reactive tinnitus, though challenging and often misunderstood, can be managed with the right clinical approach. By understanding its triggers, addressing the underlying causes, and applying desensitization techniques when appropriate, people with reactive tinnitus can experience meaningful and lasting improvement. If you have reactive tinnitus, we invite you to set up a free consultation with one of our NeuroMed team members to learn how we can help.

References

[1]        T. Spisila, L. C. Fontana, R. Hamerschmidt, R. de Cássia Cassou Guimarães, and P. B. Hilgenberg-Sydney, “Phenotyping of somatosensory tinnitus and its associations: An observational cross-sectional study,” J. Oral Rehabil., vol. 51, no. 10, pp. 2008–2018, Oct. 2024, doi: 10.1111/joor.13783.

[2]        N. M. Surina et al., “Neuroinflammation in Pathogenesis of Audiogenic Epilepsy: Altered Proinflammatory Cytokine Levels in the Rats of Krushinsky-Molodkina Seizure-Prone Strain,” Biochem. Biokhimiia, vol. 88, no. 4, pp. 481–490, Apr. 2023, doi: 10.1134/S0006297923040041.

[3]        M. Abouzari et al., “Efficacy of Multi-Modal Migraine Prophylaxis Therapy on Hyperacusis Patients,” Ann. Otol. Rhinol. Laryngol., vol. 129, no. 5, pp. 421–427, May 2020, doi: 10.1177/0003489419892997.