Hyperacusis: causes, symptoms, treatment and when earplugs help

A spoon tapping against a cup, the beep of the microwave, a colleague laughing. For most people those are ordinary sounds. If you have hyperacusis, you experience them as too loud, sharp or even painful. As if someone has turned the volume of the world up a few notches too high.

The word hyperacusis comes from Greek and means something like: I hear too much. In this article you will read what is going on, how to recognise it and have it diagnosed, what helps, and why earplugs only belong in really loud noise.

What exactly is hyperacusis?

Everyone has their own limit for how loud sound can be. You notice it in how loud someone sets the television or listens to music. With hyperacusis, that limit is much lower. Sounds that other people find normal become unbearable.

Normally your hearing constantly adapts to changing sound levels. If the radio is on while someone is talking quietly to you, you hear both without either becoming too much. That ability to cope with large and rapid differences in volume is called the dynamic range. With hyperacusis, that range is smaller. You often hear quiet sounds perfectly well, but as soon as something gets a little louder, it shoots straight to too loud. Rapid changes, such as a door slamming, are extra difficult.

The amplification in your hearing system and brain probably plays a large part. If your brain receives less signal from the ear, for example after noise damage, it can turn the amplification up. That explains why hyperacusis and tinnitus so often occur together. How that amplification works is explained in how your brain creates tinnitus. If you first want to understand how sound travels through your ear to your brain, read how hearing works.

Want to see and hear how your ear processes pitch? With the demo below you play a tone and see where it lands in your cochlea.

Do you have hyperacusis yourself? Then turn your volume down first. The tone stops by itself after 30 seconds.

Symptoms: how do you recognise hyperacusis?

The clearest sign is that ordinary sounds come in too loud. People with hyperacusis describe, for example:

• voices that sound shrill or piercing, especially children’s voices
• kitchen sounds such as crockery, cutlery or a kettle that hurt
• music in shops or restaurants that is unbearable
• pain, pressure or a stabbing feeling in the ear with certain sounds
• tiredness, irritability or headaches after a day among people
• starting to avoid busy places, such as a birthday party or the supermarket

How severe it is varies greatly from person to person. For one person it is mainly a nuisance, for another it shapes the whole day. Because nobody can see it, the people around you often find it hard to understand.

Hyperacusis, misophonia or recruitment?

Oversensitivity to sound can take different forms. They look alike, but sometimes need a different approach.

There is also phonophobia: fear of certain sounds, often because you expect them to hurt. That fear can develop alongside hyperacusis and make the symptoms worse.

Causes of hyperacusis

A clear cause is by no means always found. What is known is that hyperacusis occurs more often after, or together with:

• Noise. A loud bang or years of noise, for example in construction, hospitality or music, can damage your hearing. This is called acoustic trauma.
• Tinnitus. The two often have a common cause, such as hearing damage. That tinnitus itself causes hyperacusis has not been proven.
• Head injury or a blow to the head, and sometimes ear surgery.
• Conditions such as Ménière’s disease, migraine, PTSD or a brain haemorrhage.
• Autism. You can read more about this below.
• Medication. Some medicines can cause or worsen oversensitivity to sound. Never stop taking them yourself, but discuss it with your doctor.

Stress and tiredness don’t cause hyperacusis, but they often make it worse. Your brain is then more tuned in to anything that might be threatening, including sound.

Hyperacusis and autism

Many autistic people experience sound more intensely. That isn’t always hyperacusis: often it is about how the brain processes and filters sensory input, and less about a discomfort threshold that is too low in the hearing itself. The two can occur together, though, and the symptoms are similar. Sounds come in too loud or too many at once, and busy situations cost a lot of energy.

The difference matters, because the approach is partly different. With sensory overload, earplugs with a filter can help you cope in busy situations. With hyperacusis, the aim is precisely for your ears to get used to ordinary sounds again. In both cases: use them selectively, not all day. More about earplugs for sensory overload, for children and adults, can be found in earplugs for autism.

The hyperacusis test: how is it diagnosed?

If you think you have hyperacusis, see your GP first. They can refer you to an ENT doctor or an audiology centre. In the Netherlands, for example, GPs refer patients with hyperacusis to an audiology centre; ask your GP what is available in your country. It starts with a conversation. When did the symptoms start? Which sounds are the hardest? What does it mean for your work, your sleep and your social life? They will also check whether there is another cause that can be treated.

Then comes a hearing test. Hyperacusis also occurs when your hearing is otherwise fine, so they often measure your discomfort threshold as well. This is called the LDL test (loudness discomfort level) or UCL test (uncomfortable loudness level). Through headphones you hear tones that slowly get louder, and you indicate when it becomes unpleasantly loud. The sound then goes no higher. With hyperacusis that limit is clearly lower than average, sometimes at all pitches, sometimes at some of them.

Alongside the measurements, clinicians often use a questionnaire, such as the Hyperacusis Questionnaire. It maps out how much it bothers you in daily life, and later lets you see whether it is improving.

Self-check: does this sound familiar?

An online test cannot make a diagnosis. These questions do help you decide whether it makes sense to discuss it with your GP.

• Do you find sounds too loud that other people find normal, such as voices, crockery or traffic?
• Do some sounds hurt, or give a pressing or stabbing feeling in your ear?
• Do you avoid restaurants, birthday parties or shops because of the noise?
• Are you exhausted, tense or irritable after a day of ordinary sounds?
• Are you wearing earplugs more and more often in situations that aren't actually loud?
• Do you also have a ringing or hissing in your ears, or do you hear worse than you used to?

Do several points sound familiar, or does it bother you a lot? Then make an appointment with your GP. If you also hear ringing or hissing, our tinnitus test can help you describe more precisely what you hear.

Treatment of hyperacusis

There is no medicine for hyperacusis, and surgery only helps in exceptional cases. You can, however, learn to deal with it differently, and for many people the oversensitivity decreases as a result. Treatment usually takes place through an audiology centre.

• Explanation. The first step is understanding what is happening. Knowing that the sound isn’t damaging your ears often makes it less threatening.
• Sound therapy. Your ears and brain gradually get used to ordinary sounds again. For example, by listening every day for a short time to a sound that isn’t pleasant but isn’t too much either, and slowly building it up. Sometimes this is done with a small noise generator in the ear. Do it under the guidance of an audiologist, because if it is set incorrectly it can make the symptoms worse.
• Cognitive behavioural therapy (CBT). Stress and anxiety increase the attention you pay to sound. With a psychologist you learn to break that vicious circle and react less strongly to sound.
• Tinnitus Retraining Therapy (TRT). A combination of explanation and sound therapy that is also used for hyperacusis. It isn’t offered everywhere; ask your GP or audiology centre whether it is available in your country.
• Hearing aid for hearing loss. If you also hear worse, a well-adjusted hearing aid can help. With recruitment, a limiter is used as well.

A hearing or tinnitus patient association in your country can often answer questions, point you to care providers and put you in touch with others who have the same condition. In some countries there are also mental health services specifically for deaf and hard-of-hearing people that offer support.

When do earplugs help, and when don’t they?

This is where things often go wrong. When sound hurts, the urge to put in earplugs and keep them in is strong. Understandable, but in the long run it backfires. If you shield your ears from everyday sounds, you make them more sensitive, which keeps the symptoms going. Hospitals such as Ghent University Hospital in Belgium and the Jeroen Bosch Hospital in the Netherlands write this, among others.

Custom earplugs are therefore not a treatment for hyperacusis. They protect your ears when it is really loud. If you also use them to cope with a busy situation, such as a crowded train or a party, do so selectively and in consultation with the person treating you. More about earplugs in busy situations can be found at earplugs for sensory overload.

Living with hyperacusis

Because it is invisible, people with hyperacusis don’t always get understanding. “It isn’t that loud, is it?” Still, it helps to talk about it. Explain to the people around you what you experience, so they can take it into account, for example with a quieter seat at the table or the music a bit lower.

Recognition makes a big difference. Knowing that you are not the only one and that it is a real condition takes away some of the tension. Contact with others who have it, for example through a patient association, can help. And if you can’t manage it on your own, ask for help. An audiology centre or psychologist can give you exercises to use in daily life.

Preventing oversensitivity to sound

Not every form of hyperacusis can be prevented. Noise damage can, and that is one of the known causes. So protect your ears at concerts, festivals, during DIY and in noisy work, and don’t turn your headphones up louder than necessary. Why sound can damage your hearing before it hurts is explained in what is sound? Everything about tinnitus, sound dose and what you can do yourself can be found on our page about tinnitus and ringing in the ears.

Tinnitus and ringing in the earsHyperacusis and tinnitus often go togetherExplanation, a test with real sounds and what you can do yourself. Go to the tinnitus page

Sources

• Jeroen Bosch Hospital, the Netherlands (in Dutch): Oversensitive to sound: tips for coping with hyperacusis
• Ghent University Hospital, Belgium (in Dutch): Tips for tinnitus and hyperacusis (pdf)
• Stichting Hoormij, Dutch patient association (in Dutch): Hyperacusis and Treatments
• Khalfa, S. et al. (2002): Psychometric normalization of a hyperacusis questionnaire, ORL

Your own doctor can advise you on the rules and options in your country.