Secondary Conditions to Tinnitus: Insomnia, Migraines, Sleep Apnea

The conditions most often service-connected as secondary to tinnitus are insomnia and other sleep problems, headaches and migraines, depression, and anxiety. Each is claimed under 38 C.F.R. § 3.310 and needs its own diagnosis and a clinician's opinion explaining how the tinnitus caused it or made it worse. Sleep apnea is different: tinnitus does not affect the airway, so sleep apnea secondary to tinnitus is a theory that rarely holds up, and there are usually better routes for it.

Why this matters: tinnitus is rated at a single 10 percent under DC 6260 (38 C.F.R. § 4.87), no matter how loud it is. The conditions it leads to are rated on their own criteria, and they can be worth far more than the tinnitus itself.

How a secondary claim to tinnitus works

Under 38 C.F.R. § 3.310, a disability that is caused by a service-connected condition, or made worse by it beyond its natural course, is service-connected too. For every condition below, the claim needs three things:

1. 1Service-connected tinnitus. If you haven't been granted tinnitus yet, that comes first, and both can be filed together.
2. 2A current diagnosis of the secondary condition, from a clinician who can make it.
3. 3A nexus opinion saying the tinnitus is "at least as likely as not" (50 percent or greater) the cause or an aggravating factor, with a medical explanation grounded in your records.

Your own description of how the ringing affects you (when it is worst, what it keeps you from doing) is lay evidence the clinician can rely on. Put it in writing.

Insomnia and sleep disorders

This is the most natural secondary claim for tinnitus. The ringing is loudest in a quiet room, which is exactly when you are trying to fall asleep, and it can wake you during the night.

• How it is rated: insomnia has no diagnostic code of its own, so VA usually rates it by analogy under the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130), at 0, 10, 30, 50, 70, or 100 percent. "Chronic sleep impairment" appears at the 30 percent level.
• The catch: if you are already rated for PTSD, depression, or another mental health condition, sleep impairment is usually already counted in that rating, and VA won't rate the same symptom twice (38 C.F.R. § 4.14).

The full guide: Insomnia secondary to tinnitus: VA rating, 38 CFR, and the nexus letter.

Headaches and migraines

Chronic tinnitus, the stress it causes, and the sleep it costs can lower the threshold for headaches. Veterans claim both tension-type headaches and migraines secondary to tinnitus.

• How it is rated: migraines are rated under DC 8100 at 0, 10, 30, or 50 percent, based on how often you have prostrating attacks, the kind that force you to stop and lie down.
• What makes it stronger: a headache diagnosis in your records, a headache diary, and notes showing the headaches increased along with the tinnitus or the sleep loss it causes.
• Watch for: a head injury or neck condition in your file. If your tinnitus came from a TBI, the headaches may be better claimed secondary to the TBI.

See Headaches secondary to tinnitus and Migraines (DC 8100): prostrating attacks.

Depression and anxiety

Living with a sound that never stops can wear a person down. Depression and anxiety disorders are claimed secondary to tinnitus when a mental health clinician diagnoses them and links them to the tinnitus.

• How they are rated: under the General Rating Formula for Mental Disorders (38 C.F.R. § 4.130), at 0, 10, 30, 50, 70, or 100 percent.
• One rating, not several: if you have more than one mental health diagnosis, VA generally rates them together under one evaluation. Insomnia, depression, and anxiety secondary to tinnitus usually end up as one mental health rating, not three.

See Depression secondary to tinnitus and Anxiety secondary to tinnitus.

Can I claim sleep apnea secondary to tinnitus?

You can file it, but it is one of the weakest secondary theories there is, and it is worth knowing why before you pay for a nexus letter.

Obstructive sleep apnea is a problem with the airway: the throat collapses during sleep and breathing stops, which a sleep study measures. Tinnitus is a problem with how the ear and brain process sound. There is no accepted medical mechanism by which ringing in the ears makes the airway collapse, so most clinicians won't sign that opinion, and a letter that simply asserts the link is easy for VA to set aside. Section 3.310 is the same rule for every secondary claim; what is missing here is the medical explanation it requires.

What a nexus letter for sleep apnea secondary to tinnitus would have to do is name a specific, medically supported way the tinnitus caused or worsened the airway problem, and cite medical literature for it. If a clinician can't do that for your records, the letter won't carry the claim.

The routes that usually work better for sleep apnea:

• Direct service connection: symptoms in service such as loud snoring, stopped breathing, or falling asleep on duty, shown in records or in statements from people who served with you. See the sleep apnea buddy letter example.
• Secondary to another condition with a recognized mechanism: chronic sinusitis or rhinitis (nasal obstruction), asthma, or, with more work, PTSD.
• If what tinnitus does is keep you awake, that is insomnia, not sleep apnea, and the insomnia claim above is the one that fits.

The nexus letter for sleep apnea guide explains what that opinion has to say.

Conditions tinnitus is secondary to

It runs the other way too. Tinnitus itself can be claimed secondary to hearing loss or a traumatic brain injury when there was no single noise event to point to. See Tinnitus secondary to hearing loss and Tinnitus secondary to TBI, and the tinnitus nexus letter guide for what the opinion needs.

Frequently asked questions

What conditions are secondary to tinnitus?

The ones veterans most often service-connect are insomnia and other sleep disorders, headaches and migraines, depression, and anxiety. Each needs its own diagnosis and a medical opinion under 38 C.F.R. § 3.310 explaining how the tinnitus caused it or made it worse.

Can I claim sleep apnea secondary to tinnitus?

You can file it, but it rarely holds up. Tinnitus does not affect the airway, and there is no accepted mechanism by which it causes obstructive sleep apnea, so most clinicians won't support that opinion. Direct service connection, or a secondary claim to sinusitis, rhinitis, asthma, or PTSD, is usually the better route. If tinnitus keeps you awake, the claim that fits is insomnia.

Can migraines be secondary to tinnitus?

They can be claimed that way under 38 C.F.R. § 3.310 when a clinician diagnoses the headaches and explains how the tinnitus, and the stress and lost sleep it causes, brought them on or made them worse. Migraines are rated under DC 8100 at 0, 10, 30, or 50 percent.

Is tinnitus worth more than 10 percent?

Not on its own. DC 6260 assigns a single 10 percent whether the sound is in one ear, both ears, or in the head. The conditions tinnitus causes are rated separately and can be worth more.