What are the treatment options for Ménière’s disease?

Treatment Options for Ménière's Disease

The primary treatment for Ménière's disease includes diuretics, betahistine, low-sodium diet, and lifestyle modifications, with surgical interventions reserved for cases unresponsive to conservative management. 1

First-Line Treatment Approach

Medical Management

• Diuretics: Recommended as primary oral medication for maintenance therapy to reduce endolymph volume

  • Options include thiazides, potassium-sparing diuretics, loop diuretics, and carbonic anhydrase inhibitors 1
  • These medications aim to alter electrolyte balance and reduce endolymphatic hydrops

• Betahistine: Offered for symptom reduction despite mixed evidence

  • Earlier studies suggested 56% reduction in vertigo compared to placebo
  • The BEMED trial found no significant difference between betahistine and placebo 1
  • Caution in patients with asthma or peptic ulcer disease
  • Contraindicated in patients with pheochromocytoma 1

• Symptomatic Relief During Attacks:

  • Antivertigo medications
  • Antiemetics
  • Antihistamines 1

Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) is strongly recommended 1, 2
• Limit alcohol and caffeine intake 1, 2
• Manage stress 1
• Sleep in darkness 1
• Consider allergy management 1
• Some evidence supports gluten-free diet in selected patients 2

Second-Line Interventions

Intratympanic Treatments

• Intratympanic steroids: For patients not responsive to noninvasive treatments

  • Benefits: Improved vertigo control, quality of life, faster return to work
  • Risks: Hearing loss, eardrum perforation, persistent imbalance 1

• Intratympanic gentamicin: For persistent vertigo despite medical management

  • Low-dose approach preferred to reduce vestibular function without complete ablation 3
  • Effective for vertigo control but carries risk of hearing loss 3

Surgical Options

For patients with disabling, persistent vertigo despite other treatments:

• Endolymphatic sac decompression: Reduces endolymphatic pressure while preserving hearing 1, 4
• Vestibular nerve section: Severs vestibular portion of cranial nerve VIII for vertigo control 1
• Labyrinthectomy: Removes labyrinth, controlling vertigo but sacrificing remaining hearing 1

Special Considerations

Bilateral Disease (10-25% of cases)

• Requires caution with ablative procedures to avoid total vestibular loss 1
• Corticosteroids may be particularly beneficial if autoimmune basis is suspected 5

Additional Supportive Therapies

• Vestibular rehabilitation: Beneficial for chronic imbalance between attacks (not during acute episodes) 1
• Hearing aids: Recommended for patients with hearing loss 1

Treatment Duration and Monitoring

• Treatment duration not well established (most betahistine studies cover only 2-12 weeks) 1
• Consider tapering or stopping medication once symptoms subside 1
• Regular audiologic and vestibular assessment recommended to monitor clinical course 6

Important Caveats

• No cure exists for Ménière's disease, only symptom management 1
• Patient education is crucial for shared decision-making 1
• The Meniett device (positive pressure therapy) is not recommended based on systematic reviews 1
• Bilateral involvement occurs in 25-40% of cases and requires special consideration 6
• Treatment efficacy should be regularly assessed as the disease may naturally remit in some patients 1