Ginkgo biloba for tinnitus: Cochrane review verdict

Ginkgo biloba is one of the most widely used herbal supplements in the world and has been a popular self-treatment for tinnitus for decades. The proposed mechanism involves improved cerebrovascular circulation and free-radical scavenging, both of which sound plausible for a condition sometimes attributed to cochlear blood flow problems. Multiple clinical trials have put these claims to the test. The results have been consistently disappointing.

Why ginkgo was tried for tinnitus

The theoretical case for ginkgo in tinnitus is not unreasonable in isolation. Extracts of ginkgo biloba leaves contain flavone glycosides and terpene lactones with demonstrated effects on platelet aggregation, blood viscosity, and vascular tone in laboratory settings. Because some forms of tinnitus, particularly pulsatile tinnitus, are associated with vascular factors, and because inner ear blood flow is difficult to assess clinically, a vasoactive herb seemed worth studying.

Ginkgo also has antioxidant properties, and oxidative stress is implicated in cochlear hair cell damage. These properties provided a theoretical rationale that appealed to both clinicians and patients in the 1980s and 1990s, before large-scale randomized trials were conducted.

What the trials found

Multiple randomized placebo-controlled trials of ginkgo biloba for tinnitus have been conducted since the 1980s. The most influential trials include:

A large multicenter trial conducted in Germany enrolled 1,121 patients and compared ginkgo extract EGb 761 against placebo over 12 weeks. No statistically significant difference was found in tinnitus outcomes between the groups.

A UK Medical Research Council trial specifically recruited patients whose primary complaint was tinnitus. The trial compared ginkgo extract to placebo over 12 weeks and found no meaningful difference in tinnitus loudness, frequency of episodes, or distress between groups. The authors noted that the placebo response was substantial in both arms.

A Cochrane systematic review examining the evidence from multiple trials concluded that existing evidence did not demonstrate ginkgo biloba to be effective for tinnitus. The review authors noted methodological limitations across the trials but found that even accounting for these limitations, the overall direction of evidence did not support clinical use for tinnitus.

The AAO-HNS 2014 tinnitus clinical practice guideline explicitly recommends against recommending ginkgo biloba for tinnitus management, citing the absence of evidence supporting its efficacy.

Why the results matter for patients

The consistent negative results from methodologically adequate trials do not mean ginkgo biloba is dangerous or that no one has ever experienced relief after taking it. Tinnitus has a high placebo response rate, meaning that many people improve with any intervention they believe is active. If someone starts ginkgo during a period when their tinnitus would have improved anyway, attributing the improvement to the supplement is a natural but incorrect inference.

For patients spending money on supplements for tinnitus relief, the lack of demonstrated efficacy in multiple trials is important information. It does not mean an individual’s experience of improvement is not real, but it does mean the supplement is unlikely to be the cause.

Safety considerations

Ginkgo biloba is generally well tolerated. The most clinically important concern is its antiplatelet activity. Ginkgo inhibits platelet-activating factor, reducing platelet aggregation in a manner somewhat similar to aspirin. This effect can potentiate the action of anticoagulant and antiplatelet drugs including warfarin, clopidogrel, and aspirin, increasing bleeding risk.

Patients taking blood thinners for cardiovascular disease should not start ginkgo biloba without discussing it with their prescribing clinician. The interaction is not theoretical: case reports of spontaneous bleeding episodes in patients combining ginkgo with anticoagulants have been published in the medical literature.

Other reported side effects include gastrointestinal upset and headache. Allergic reactions are possible, particularly in people who are sensitive to plants in the Anacardiaceae family (which includes poison ivy and cashews). At standard doses for healthy adults not taking interacting medications, the safety profile is acceptable, but the absence of benefit for tinnitus means taking the risk for no return.

What the evidence does support for tinnitus

Therapies with the strongest evidence for tinnitus management address either the psychological impact of tinnitus or the auditory system’s adaptation to it. Cognitive behavioral therapy for tinnitus has consistent evidence from multiple trials showing reduction in tinnitus-related distress and improved quality of life. Sound therapy, including sound masking and acoustic enrichment, is widely recommended by audiologists and supported by AAO-HNS guidelines. Hearing aid fitting in patients with concurrent hearing loss improves both hearing function and tinnitus perception in many patients.

These approaches require more effort than taking a supplement and lack the simple appeal of a pill. But their evidence base is substantially stronger than ginkgo’s.

The broader supplement landscape for tinnitus

Ginkgo biloba is not the only supplement studied for tinnitus and found wanting. Melatonin, magnesium, and B vitamins have all been studied with similarly limited results in unselected tinnitus populations, though zinc has a somewhat different and more nuanced evidence picture that relates specifically to deficient patients.

Patients encountering supplement marketing for tinnitus should be aware that the regulatory environment in most countries does not require demonstrations of efficacy before such products are sold. The Cochrane review and multiple independent trials represent a more reliable evidence base than the testimonials typically featured in supplement advertising.

If symptoms persist or change, see an audiologist or physician.