Is Ringing in the Ears a Benzodiazepine Withdrawal Symptom, and Does It Go Away?

Is ringing in the ears a benzodiazepine withdrawal symptom?

Yes. Tinnitus is a ringing, hissing, or buzzing that only the person hearing it can hear, and it appears in the Ashton Manual’s list of benzodiazepine withdrawal symptoms (Chapter III, Table 1). Professor C. Heather Ashton, who wrote the Manual, called it one of the most distressing sensory symptoms of withdrawal.

Official labeling says the same. The class-wide label changes that followed the 2020 boxed warning update from the United States Food and Drug Administration (FDA) describe a protracted withdrawal syndrome, and tinnitus is named among its symptoms.

So, a person whose ears begin to ring partway through a taper is not imagining it and has not done anything wrong. A prescribed medication was taken as directed, and the body adapted to it. Physical dependence is not addiction, and a ringing ear after a dose reduction is a sign of a nervous system adjusting to less medication.

Why would a taper make the ears ring?

Nobody knows for certain. Professor Ashton wrote in Chapter III of the Ashton Manual that whether people who have taken benzodiazepines long term are especially prone to tinnitus, and if so why, is not known. What follows is the most likely explanation, not a settled fact.

Benzodiazepines boost the action of gamma-aminobutyric acid (GABA), the brain’s main calming signal. Over months and years, the nervous system adapts to that extra calming. When the drug is withdrawn, the Manual explains, nearly all of the excitatory mechanisms in the nervous system go into overdrive, and it lists a heightened sensitivity to all sensations, hearing included, as a characteristic feature of withdrawal.

A stereo amplifier makes a useful comparison. With the volume knob low, the system is silent between songs. With the knob turned far up in a quiet room, the hiss of the equipment itself can be heard, though nothing is wrong with the speakers.

In withdrawal, the gain on the hearing pathways appears to be turned up, and the brain starts to hear its own background noise. That is why withdrawal tinnitus, in most cases, does not mean the ears have been damaged. The answer is to make each change small and give the system time to settle, not to replace the speakers.

Should the ears be checked anyway?

Often, yes. Tinnitus is not uncommon in people with some hearing loss who have never taken a benzodiazepine, and Professor Ashton observed that it often makes its first appearance during withdrawal in people who have had hearing loss for years.

A hearing test is reasonable when the ringing began before the taper, when it stays in one ear, or when it does not seem to follow dose changes at all. Professor Ashton noted that the ringing can sit in one ear even when the hearing loss is the same on both sides, so a one-sided sound does not rule out withdrawal. It is still worth a look.

Some patterns should not wait. Sudden hearing loss in one ear, ringing that arrives with spinning vertigo, or a sound that pulses in time with the heartbeat should be seen by a physician promptly, without waiting for the next taper visit. An ear, nose, and throat physician or an audiologist can look for causes that have nothing to do with the medication.

Yet, finding one does not cancel the taper. It means that two things are going on, and each needs its own attention.

Does tinnitus from benzodiazepine withdrawal go away?

Fortunately, for most people it fades. For some, it takes a long time, and an honest answer has to include both halves.

The Manual lists tinnitus with the sensory symptoms of protracted withdrawal and gives their usual course as gradually receding, though they may last at least a year and occasionally several years (Chapter III, Table 3). Professor Ashton added that it does not always respond to the usual tinnitus treatments, such as maskers. The FDA label language describes protracted symptoms lasting from weeks to more than 12 months.

Along the way, the sound rarely holds steady. The Manual notes that withdrawal symptoms characteristically wax and wane, and the ringing tends to be louder after a cut, after a poor night, or under stress, and quieter in the good stretches. Those quieter stretches usually grow longer with time.

No one can promise a date, and anyone who does is guessing. What can be said is that a gradual taper gives the nervous system better conditions to settle, and that the question of how long protracted benzodiazepine withdrawal lasts has a more hopeful answer than it seems to have on a loud day.

What helps while the ringing is there?

The taper itself is the main tool. In the practice of Dr. Mark Leeds, an osteopathic physician and deprescribing specialist in Fort Lauderdale, Florida, new or louder ringing after a reduction is treated as information about the pace. The usual first response, agreed with the patient, is to hold at the current dose until things settle, then continue with smaller steps.

This follows the Ashton Manual, which says that the person tapering must be in control and must proceed at a comfortable pace, and that a person can stand still at a stage of the schedule for a few weeks before going on (Chapter II). So, a hold is not a failure. It is the plan working as designed.

Beyond pacing, the measures are supportive, and the evidence for each is limited. Low background sound at night, such as a fan or a white noise machine, gives the brain something else to listen to, though Professor Ashton’s caution about maskers applies. Protecting sleep matters, because the ringing is usually harder to bear after a bad night, and insomnia during a benzodiazepine taper deserves attention of its own.

Hearing protection makes sense around loud noise. Alcohol acts on the same GABA receptors as benzodiazepines, so it is best avoided during a taper, because it can unsettle the nervous system all over again. Many people who are tapering also find that the ringing is quieter when caffeine stays modest.

Some patients find that working with a therapist on the distress the sound causes helps, which is a personal choice and not a part of the taper. Supplements sold for tinnitus come up often, but the evidence for them is limited, individual response varies, and the decision belongs with the patient and a physician who understands the pharmacology. And, none of them replaces a gradual taper.

What should a person not do about it?

Two reactions make sense in the moment and tend to backfire. The first is to speed up and get the taper over with.

A faster taper asks more of a nervous system that is already overexcited, and stopping abruptly can bring severe withdrawal, including seizures. A seizure, or any other medical emergency, is a reason to call emergency services right away.

The second is to chase the sound with something new. Unfortunately, a person who mentions ringing ears and poor sleep in a short appointment may walk out with a prescription for another sedating drug. A sedative added in the middle of a taper is one more medication that may later need a taper of its own, and it does nothing about why the ears are ringing.

Whether to add anything is a decision for the patient and a physician who understands benzodiazepine withdrawal, weighing risks against benefits. It should not be a reflex.

Does it matter whether the medication is Klonopin, Xanax, or another benzodiazepine?

Tinnitus belongs to benzodiazepine withdrawal as a class, and the Manual’s symptom table does not sort it by drug. Yet, the drug shapes how a taper feels.

Clonazepam (Klonopin) is, by the Manual’s equivalence table (Table 1 in its first chapter), about twenty times as strong as diazepam (Valium), milligram for milligram. So, even a sliver shaved off a tablet is a large step, and the Manual notes that a smooth, slow fall in blood level is difficult to achieve with this drug (Chapter II). Because clonazepam leaves the body over days, the effect of a cut can lag, and ringing that starts a week after a reduction may still be tied to it.

Alprazolam (Xanax) is just as potent and much shorter acting, so the level falls between doses, and some people notice the ringing rise before the next dose is due. For both drugs, the Manual’s answer is a crossover taper to diazepam, where it helps, because diazepam allows smaller and smoother steps. The same reasoning runs through a Klonopin taper and a Xanax taper.

Questions patients ask about tinnitus and tapering.

Do benzodiazepines treat tinnitus?

Benzodiazepines have sometimes been prescribed for tinnitus. No benzodiazepine is approved for that use, and the evidence that they help is limited. A prescription given without a conversation about the risks, including physical dependence, the alternatives, an exit plan, and the right to decline is one way people become dependent without ever being told it could happen.

For a person who started this way, ringing during a taper may be the original tinnitus, withdrawal, or both. Often, that cannot be sorted out until the taper is finished and the nervous system has had time to settle.

Should the dose go back up when the ringing starts?

A hold usually comes first. The Ashton Manual advises against going backwards as far as possible, and Professor Ashton observed that tinnitus is not always relieved by restarting a benzodiazepine. Dr. Leeds regards a small updose as a legitimate choice when a cut has proved too large, decided together with the patient, which is very different from abandoning the taper.

Why would the ringing start late in a taper, at a low dose?

Equal-sized cuts take a larger share of what is left as the dose falls. The Maudsley Deprescribing Guidelines describe hyperbolic tapering for this reason: each step is sized to the current dose, so the steps get smaller as the dose gets lower. So, ringing that first appears near the end of a taper may be a sign that the steps have not shrunk enough.

The pace of a taper should answer to symptoms like this one.

Dr. Leeds’ practice offers one service: medically supervised tapering of benzodiazepines and z-drugs for patients in Florida. It is a concierge practice with one physician, so the person who writes the taper plan is the person who hears how the last reduction went. Tapers are gradual, patient directed, and adapted to the person, and they run for months, sometimes longer.

Ringing ears during a taper are a reason to slow down and to be heard. They are not a reason to rush, and they are not a reason to give up. For a person in Florida who wants a taper paced to the nervous system, Dr. Leeds’ practice in Fort Lauderdale is a place to start. Contact Dr. Leeds to ask about a gradual, medically supervised taper.

This article is educational. It is not medical advice, and reading it does not create a doctor-patient relationship. Decisions about starting, continuing, or tapering any medication should be made with your own physician.