What are the treatment options for Meniere disease?

Treatment Options for Meniere's Disease

For patients with Meniere's disease, a stepwise approach beginning with lifestyle modifications and oral medications should be used first, progressing to intratympanic treatments and surgical interventions only for cases unresponsive to conservative management. 1, 2

First-Line Management

Lifestyle and Dietary Modifications

• Low-sodium diet (1500-2300 mg daily) is recommended as a first-line approach 2
• Limiting alcohol and caffeine consumption 2
• Stress management techniques 2
• Allergy management when applicable 2
• Sleeping in darkness may help reduce symptoms 2

Pharmacological Options

• Oral medications for maintenance therapy:
  • Diuretics (thiazides) to reduce endolymph volume 1, 2
  • Betahistine may be offered to reduce symptoms or prevent attacks 1, 2
  • Antivertigo medications, antiemetics, and antihistamines for symptomatic relief during acute attacks 2

Important note: The 2020 BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks, contradicting earlier Cochrane reviews. This represents the highest quality evidence available, suggesting betahistine's benefits may be limited 1.

Second-Line Interventions

Intratympanic Treatments

• Intratympanic steroids may be offered to patients with active Meniere's disease not responsive to noninvasive treatments 1, 2
  • Benefits: Improved vertigo control, improved quality of life, faster return to work 1
  • Risks: Hearing loss, eardrum perforation, persistent imbalance 1

Surgical Options (for disabling, persistent vertigo)

For patients with disabling vertigo despite conservative treatments, surgical options include:

1. Endolymphatic sac decompression - reduces endolymphatic pressure while preserving hearing 2
2. Vestibular nerve section - severs the vestibular portion of cranial nerve VIII while preserving hearing 2
3. Labyrinthectomy - controls vertigo but sacrifices remaining hearing; only for patients with non-serviceable hearing 2

What NOT to Use

• Positive pressure therapy (Meniett device) is not recommended as systematic reviews show no significant difference in vertigo control compared to placebo 1
• Vestibular rehabilitation/physical therapy should not be used during acute vertigo attacks 1
  • However, it can be beneficial for chronic imbalance between attacks 2

Special Considerations

• Bilateral disease (10-25% of cases) requires caution with ablative procedures to avoid total vestibular loss 2
• Hearing aids can be beneficial for patients with hearing loss 2
• Patient education is crucial for shared decision-making 2

Treatment Algorithm

1. Initial management: Lifestyle modifications + oral medications (diuretics and/or betahistine)
2. If vertigo persists: Consider intratympanic steroid injections
3. For refractory cases: Consider surgical options based on hearing status:
   • Good hearing → Endolymphatic sac decompression or vestibular nerve section
   • Poor hearing → Labyrinthectomy

Monitoring and Follow-up

• Regular audiologic and vestibular assessment to monitor disease progression
• Address quality of life impact, including psychological aspects such as anxiety and depression 2

Caveat: There is no cure for Meniere's disease, only symptom management. Treatment expectations should be discussed with patients 2.

Emerging Research Areas

Current guidelines note several areas needing further research, including the role of migraine management, optimal duration of trigger avoidance, and standardization of intratympanic treatment protocols 1.