Moderate therapeutic efficacy of positron emission tomography-navigated repetitive transcranial magnetic stimulation for chronic tinnitus: a randomised, controlled pilot study

C Plewnia1, M Reimold2, A Najib3, G Reischl4, S K Plontke5, C Gerloff6

1 Brain-Stimulation Laboratory, Department of Psychiatry, University of Tuebingen, Tuebingen, Germany
2 Department of Nuclear Medicine, PET Center, University of Tuebingen, Tuebingen, Germany
3 Hertie-Institute for Clinical Brain Research, Department of General Neurology, Cortical Physiology Research Group, University of Tuebingen, Tuebingen, Germany
4 Department of Nuclear Medicine, Radiopharmacology Section, University of Tuebingen, Tuebingen, Germany
5 Department of Otorhinolaryngology–Head and Neck Surgery, Tuebingen Hearing Research Center, University of Tuebingen, Tuebingen, Germany
6 Department of Neurology, Center of Clinical Neurosciences, University Medical Center Hamburg-Eppendorf, Hamburg, Germany


Correspondence to:
Correspondence to:
C Plewnia
Department of Psychiatry, Brain-Stimulation Laboratory, University of Tuebingen, Osianderstrasse 24, D-72076 Tuebingen, Germany; christian.plewnia@uni-tuebingen.de

Background: Tinnitus has been shown to respond to modulations of cortical activity by high-frequency and low-frequency repetitive transcranial magnetic stimulation (rTMS).

Objective: To determine the tinnitus-attenuating effects of a 2-week daily regimen of rTMS, navigated to the maximum of tinnitus-related increase in regional cerebral blood flow.

Methods: Six patients with chronic tinnitus were enrolled in this sham-controlled crossover study and treated with 2x2 weeks of suprathreshold 1 Hz rTMS (30 min) applied to the region with maximal tinnitus-related increase in regional cerebral blood flow delineated by functional imaging with [15O]H2O positron emission tomography and a control area. Tinnitus-related distress was assessed before and after each treatment and 2 weeks after the end of the 4-week course of stimulation using a validated tinnitus questionnaire. Additional self-assessment scores of tinnitus change, loudness and annoyance were obtained.

Results: In five of six patients, rTMS induced greater reduction of the tinnitus questionnaire score than sham stimulation. In two patients, all parameters measured (tinnitus change score, tinnitus loudness, tinnitus annoyance) showed unequivocal improvement. At the group level, the degree of response in the tinnitus questionnaire score was correlated with tinnitus-associated activation of the anterior cingulate cortex. Two weeks after the final stimulation, tinnitus had returned to baseline in all patients but one.

Conclusion: Tinnitus can be attenuated by low-frequency rTMS navigated to each person’s maximum tinnitus-related cortical hyperactivity. The effects are only moderate; interindividual responsiveness varies and the attenuation seems to wear off within 2 weeks after the last stimulation session. Notably, tinnitus-related anterior cingulate cortex activation seems to predict the response to rTMS treatment.