An estimated 50 million Americans have tinnitus, a condition commonly known as "ringing in the ears," where the perception of ringing, buzzing, or other sounds occurs in the absence of actual noise. The condition worsens with age and is more common among men. The leading cause of tinnitus is overexposure to noise; musicians, military personnel, and others who work near loud noise or machinery are especially at risk. According to the American Tinnitus Association, tinnitus is the most common service-related disability among veterans, and the diagnosis has increased at a rate of 15% each year since 2005. Individuals with tinnitus describe hearing different and changing sounds such as ringing, static, rattling, or ocean waves. The sound may be present in one or both ears, or more generally in the head. Although tinnitus has many causes including age-related hearing loss, head or neck injuries, and vascular diseases, most cases are due to problems within the auditory system, especially in the cochlea or cochlear nerve. Several medications may cause or worsen tinnitus and case reports have implicated NSAIDs, antibiotics, and antihypertensive agents, among other drugs. Depression and insomnia are commonly present in patients with tinnitus. The optimal treatment of tinnitus depends on its underlying cause. Behavioral therapies include retraining therapy, biofeedback, and cognitive behavioral therapy. Some patients may try complementary approaches such as acupuncture or dietary supplements such as Lipo-Flavonoid Plus, a product that contains B vitamins, vitamin C, calcium, lemon bioflavonoid complex with eriodictyol glycoside and other ingredients. Although patient testimonials are available, there is not much evidence in the literature to support the use of this product, especially if tinnitus is chronic in nature. Minerals including zinc, copper, and manganese may decrease symptoms of tinnitus but published evidence is mixed. A new study will evaluate the effect of magnesium on tinnitus symptoms. The herb ginkgo biloba is often used to help manage tinnitus, but recent studies are small and have conflicting results. In 2010, an updated Cochrane review that included 3 studies and excluded another 10 trials due to methodological issues concluded that ginkgo lacked efficacy for tinnitus. A 2011 German systematic review included only studies using the standardized ginkgo preparation, EGb 761, a product that initially showed a benefit for Alzheimer disease. The author reported that EGb 761 was effective for tinnitus. The studies in this latter review listed tinnitus either as the primary complaint or as a complaint related to cognitive impairment. This review discounted the prior negative findings as being due to the inclusion of poorer quality products. Of note, most of the individual studies in both reviews of ginkgo have been small and have not used outcome assessment instruments such as the Tinnitus Reaction Questionnaire. Melatonin has also been used for the treatment of tinnitus with mixed results. Recently, 61 patients with chronic tinnitus were randomized in a double-blind crossover study in which they received 3 mg of melatonin or placebo for 30 days. After a 1-month washout period, patients were switched to the other treatment for an additional month. Patients in the melatonin group had improved scores on several standardized outcome measures including self-rated tinnitus. Response to melatonin was more likely among men, individuals without concomitant depression or anxiety, or prior tinnitus therapy. The mechanisms by which melatonin might improve symptoms of tinnitus are unclear. Studies of any product for tinnitus should always be placebo-controlled because a placebo response is likely possible. Tinnitus has many causes ranging from diseases to medications. Although the conditions causing tinnitus are generally not serious, physicians should carefully assess patients and refer them to an audiologist. Concomitant depression, anxiety, and insomnia should also be addressed and treated. Prescription medications and dietary supplement are generally ineffective for tinnitus. Melatonin and gingko products containing EGb 761 may have modest efficacy in some patients. Study results have generally been mixed and contradictory, however, and many ginkgo products lack key components. Limiting caffeine, alcohol, and cigarette smoking may help some patients with tinnitus. Currently, behavioral therapies taught by tinnitus specialists likely offer the best results for chronic tinnitus.ABOUT THE AUTHORAnne L. Hume, PharmD, FCCP, BCPS, is Professor of Pharmacy at the University of Rhode Island. She is also a complementary and alternative medicine editor for APhA's Handbook of Nonprescription Drugs. Anne L. Hume, PharmD, FCCP, BCPS, is Professor of Pharmacy at the University of Rhode Island. She is also a complementary and alternative medicine editor for APhA's Handbook of Nonprescription Drugs.