What medications are used to treat Meniere's disease?

Medications for Meniere's Disease

Diuretics and betahistine are the primary oral medications recommended for maintenance therapy in Meniere's disease to reduce symptoms and prevent attacks, although evidence for their efficacy is limited. 1, 2

First-Line Pharmacological Management

Maintenance Therapy

• Diuretics: Recommended to alter electrolyte balance and reduce endolymph volume

  • Types include:
    • Thiazides (inhibit sodium/chloride reabsorption)
    • Potassium-sparing diuretics (inhibit sodium-potassium exchange)
    • Loop diuretics (inhibit sodium reabsorption)
    • Carbonic anhydrase inhibitors (increase excretion of sodium, potassium, bicarbonate, water)
  • Despite widespread use, a Cochrane review found insufficient high-quality evidence supporting diuretics 1, 3

• Betahistine: May be offered for symptom reduction

  • Earlier studies suggested 56% reduction in vertigo compared to placebo
  • However, the high-quality BEMED trial found no significant difference between betahistine and placebo 1
  • Use with caution in patients with asthma or peptic ulcer disease
  • Avoid in patients with pheochromocytoma 1

Acute Attack Management

• Antivertigo medications: For symptomatic relief during attacks 2
• Antiemetics: To control nausea during attacks 2
• Meclizine: Vestibular suppressant with anticholinergic and antihistamine properties 4
• Benzodiazepines: May help alleviate anxiety during acute attacks 5

Second-Line Treatments

Intratympanic Treatments

• Intratympanic steroids: For patients with active Meniere's disease not responsive to noninvasive treatments

  • Benefits: Improved vertigo control and quality of life
  • Risks: Hearing loss, eardrum perforation, persistent imbalance 2

• Intratympanic gentamicin: For persistent vertigo despite optimal medical management

  • Reduces vestibular function in the treated ear
  • Complete ablation of vestibular function not typically required for vertigo control 6
  • Low-dose protocols may minimize hearing loss risk 6

Surgical Options (for refractory cases)

• Endolymphatic sac decompression: Reduces endolymphatic pressure 2
• Vestibular nerve section: Severs vestibular portion of cranial nerve VIII 2
• Labyrinthectomy: Last resort for patients with unilateral disease and deafness 2, 7

Adjunctive Measures

• Low-sodium diet (1500-2300 mg daily) 2
• Limiting alcohol and caffeine intake 2
• Stress management techniques 1, 2
• Allergy management for patients with inhalant or food allergies 1
• Sleeping in darkness to maintain hormonal circadian rhythm 1

Treatment Algorithm

1. Initial management:

   • Low-sodium diet + diuretic
   • Consider betahistine
   • Manage triggers (stress, allergies, caffeine, alcohol)

2. For persistent symptoms:

   • Optimize oral medication doses
   • Consider intratympanic steroids

3. For refractory vertigo:

   • Intratympanic gentamicin (low-dose protocol)
   • Consider surgical options based on hearing status

Important Caveats

• No definitive cure exists for Meniere's disease, only symptom management 2
• Bilateral disease (10-25% of cases) requires caution with ablative procedures 2
• Treatment duration is not well established - most betahistine studies covered only 2-12 weeks, while diuretic studies ranged from 10 days to 24 years 1
• Consider tapering or stopping medication once symptoms subside 1
• Over 85% of patients improve with lifestyle changes and medical treatment or minimally invasive procedures 7