Why tinnitus is worst at 3am
The pattern is so common that we can often finish the sentence for people. They fall asleep reasonably well, wake around six hours later, and the tinnitus is right there. The room is silent, the mind is alert, and the harder they try to get back to sleep, the louder it seems.
Two things are happening. First, there is no other sound. During the day, traffic, voices and the hum of the fridge give the brain plenty to listen to, and tinnitus is one signal among many. At night the contrast between tinnitus and silence is at its greatest. Second, waking in the dark puts the brain on alert. The brain treats tinnitus a little like an unexplained noise outside the house: it focuses on it to decide whether it matters. Frustration, worry about the next day and checking the clock all raise that alertness, and the tinnitus seems louder again.
Measuring the sleep problem
At a tinnitus assessment we use the Insomnia Severity Index (ISI), a seven-question scale scored from 0 to 28. Scores of 8 to 14 suggest subthreshold insomnia, 15 to 21 moderate clinical insomnia and 22 or more severe insomnia. It gives us a baseline, and a way to show you progress when we review.
We measure it separately because sleep and tinnitus feed each other. Poor sleep makes tinnitus more intrusive the next day, and intrusive tinnitus makes sleep worse.
Why earbuds are a poor fix
Many people discover that playing something through earbuds or AirPods gets them back to sleep. It works in the short term, which is why it catches on. It has three problems.
- Earbuds are uncomfortable to sleep in, especially on your side, and they fall out.
- They block the ear canal, cutting out the ordinary background sound that helps the brain ignore tinnitus.
- People tend to turn the volume up until the tinnitus disappears. Covering tinnitus completely brings relief while the sound plays, and the tinnitus seems louder when it stops.
What works better
Sound at night, played outside the ear. A bedside speaker, or a soft Bluetooth sleep headband or sleep mask with flat speakers built in. Both let you play sound all night without anything in your ears. Choose a sound you find pleasant, such as rain, ocean or a gentle fan, and set it just below the tinnitus, so you can still hear the tinnitus faintly. The aim is to take the edge off the silence, not to drown the tinnitus out. Apps such as Widex Zen and ReSound Tinnitus Relief have libraries of sounds designed for this, and let you build a playlist.
Leave it running. A sound that switches off after 30 minutes can leave you waking to silence. Set it to run all night.
A consistent routine. Go to bed and get up at the same time every day, including weekends. Keep the bedroom for sleep. If you have been awake for what feels like 20 minutes, get up, do something calm in dim light, and return when you feel sleepy.
Something to do with your mind. A guided relaxation or breathing exercise gives your attention somewhere to go other than the tinnitus. The Calm app and similar tools are a reasonable start.
Limit the usual suspects. Caffeine after midday, alcohol close to bedtime and screens in bed all make waking more likely.
People sometimes try earplugs, antihistamines or magnesium. Earplugs usually make tinnitus more noticeable because they remove outside sound. Talk to your GP before taking anything for sleep.
When to get help
If tinnitus is costing you sleep most nights, it is worth an assessment. We check your hearing, including above 8000 Hz, measure your tinnitus and sleep, and set up a plan with sound therapy, sleep strategies and follow-up. Where insomnia is severe, cognitive behavioural therapy for insomnia (CBT-I) has strong evidence, and we can suggest a referral through your GP.
