Next-generation neuromodulation in tinnitus: multimodal approaches and deep targets

Tinnitus affects an estimated 14% of adults worldwide, and when accompanied by cognitive strain or emotional distress, it is classified as tinnitus disorder. Despite decades of investigation, no widely applicable therapy reliably reduces the percept itself, as current clinical mainstays mostly attenuate distress. This perspective article synthesizes recent advances in neuromodulation and argues for a strategic pivot from unimodal, open-loop cortical stimulation to multimodal, circuit-informed, and depth-capable interventions. We summarize mechanistic frameworks that implicate three partially overlapping pathways: lateral auditory generators, medial salience-attention evaluators, and descending inhibitory “noise-canceling” pathways whose imbalance is thought to sustain the percept and its affective load. Evidence across repetitive transcranial magnetic stimulation and transcranial electrical stimulation indicates reproducible but modest, short-lived improvements in standard outcomes, with high heterogeneity and unclear dose verification. Peripheral approaches such as transcutaneous electrical nerve stimulation show signals of efficacy in selected phenotypes but are vulnerable to expectancy effects. By contrast, bimodal auditory-somatosensory protocols demonstrate larger and more durable benefits in recent trials, consistent with timing-sensitive plasticity and engagement of neuromodulatory systems. We further highlight emerging depth-capable methods, including low-intensity transcranial focused ultrasound and transcranial photobiomodulation, which can non-invasively modulate corticothalamic hubs implicated in tinnitus. Building on these, we propose multimodal sequencing with direct engagement of deeper network nodes across the lateral, medial, and descending pathways. Durable relief rarely comes from a single open-loop intervention. An integrated programme that combines multimodal stimulation, deeper and cleaner targeting, and personalization offers the most credible route to clinically meaningful, generalizable benefit in defined tinnitus subgroups.