Hyperacusis and Tinnitus: When Sound Becomes Painful

Hyperacusis is a disorder of loudness perception in which ordinary sounds — conversation, traffic, running water — are experienced as uncomfortably or even painfully loud. It co-occurs with tinnitus in a significant proportion of cases, and the two conditions share a common mechanism: central auditory gain turned up too high.

What Causes Hyperacusis

The central auditory system regulates how loudly the brain amplifies incoming sound. In hyperacusis, this gain control is disrupted — the brain amplifies all sound too aggressively. Common triggers include noise trauma, head injury, viral illness affecting the inner ear, Lyme disease, and certain medications. In some cases it develops alongside anxiety or PTSD without a clear physical cause.

Paradoxically, the natural instinct to protect against sound by wearing earplugs or avoiding noisy environments often worsens hyperacusis over time. Auditory deprivation causes the brain to further increase its gain, making sounds seem louder when they return.

Symptoms

• Discomfort, pain, or distress from everyday sounds at normal volumes
• Fear or anticipatory anxiety about being in noisy environments
• Physical pain in the ear from sounds that others find tolerable
• Co-occurring tinnitus, often high-pitched
• Social withdrawal or noise avoidance behaviors

Treatment

Sound desensitization therapy is the primary treatment for hyperacusis. It involves controlled, gradual re-exposure to sound at low levels, slowly recalibrating the auditory system's gain. This is the opposite of what most patients instinctively do — avoidance worsens the condition.

Tinnitus retraining therapy (TRT) addresses both hyperacusis and tinnitus simultaneously through a combination of low-level sound therapy and directive counseling. CBT is a critical adjunct for managing the fear and avoidance behaviors that sustain and amplify the condition.