Treatment

Conservative treatments

Initial treatment often focuses on relieving distress and improving coping. Sound therapy can be helpful, using either hearing aids with sound generators or background noise from table-top devices or apps. Education, counselling and psychological therapies such as cognitive behavioural therapy (CBT) or acceptance and commitment therapy (ACT) may also reduce distress. Relaxation techniques and good sleep habits can improve quality of life. Managing underlying health factors is important, including controlling blood pressure, treating anaemia or thyroid problems, and supporting weight loss and medication use in idiopathic intracranial hypertension.

Venous sinus stenting {Pulsatile Tinnitus}

Venous sinus stenting is a minimally invasive procedure that places a stent inside the narrowed sinus to improve blood flow and reduce turbulence. It is used for stenosis related to idiopathic intracranial hypertension, for primary venous sinus narrowing, and in selected cases of sigmoid sinus diverticulum or venous aneurysm.

The procedure is considered when pulsatile tinnitus is persistent and bothersome, and imaging confirms significant venous sinus stenosis, usually after conservative approaches have been tried. It is most often offered in situations such as IIH with transverse sinus stenosis and a measurable pressure gradient, primary venous narrowing without raised intracranial pressure, or residual narrowing after venous sinus thrombosis. Selection is typically based on a pressure difference of at least 6 to 8 mmHg and narrowing of more than 50 percent.

Preparation includes dual antiplatelet therapy and imaging to plan the procedure. Access is usually through the femoral vein under local or general anaesthesia. Pressure measurements are taken across the venous system, and if necessary a balloon is used to open the narrowing before placing a self-expanding stent. Repeat imaging confirms the result. Patients are monitored afterwards for bleeding or access site problems, and antiplatelet therapy is continued for several months.

The most common side effects are mild and temporary, such as headache or a small groin bruise. Less common risks include the need for further treatment in idiopathic intracranial hypertension, in-stent narrowing, or complications from contrast dye or medication.

Outcomes are generally very positive. Many patients experience immediate relief, and large studies report resolution or major improvement in the majority, with overall success rates approaching 90 percent. Systematic reviews confirm high rates of improvement with low complication rates, although a small number of patients may need repeat procedures.

Aftercare and follow-up

After the procedure, patients usually continue dual antiplatelet therapy for three to six months, followed by long-term aspirin if advised. Management of idiopathic intracranial hypertension, such as weight loss and medication, remains important when relevant. Ongoing monitoring includes tracking the pattern of tinnitus, regular eye checks for papilloedema in IIH, and management of blood pressure and cardiovascular risk factors. Follow-up imaging may be needed if symptoms persist or recur. Urgent medical help should be sought if there is sudden severe headache, new neurological symptoms, sudden visual loss, or ear pain with bleeding.