Treatment for Meniere's Disease
The primary treatment for Meniere's disease involves a stepwise approach beginning with lifestyle modifications and medical therapy, progressing to intratympanic interventions and surgical options for refractory cases, with the goal of reducing vertigo attacks and preserving hearing function. 1, 2
First-Line Treatment Options
Lifestyle Modifications
- Low-sodium diet (1500-2300 mg daily) 2
- Limiting alcohol and caffeine intake
- Stress management techniques
- Regular sleep patterns in darkness
- Allergy management when applicable
Medical Management
Diuretics (thiazides, potassium-sparing diuretics, loop diuretics, carbonic anhydrase inhibitors)
- Mechanism: Alter electrolyte balance and reduce endolymph volume
- Note: Despite widespread use, high-quality evidence supporting efficacy is limited 2
Betahistine
- Dosage: Typically 16-48 mg daily divided into doses
- Contraindications: Use with caution in asthma or peptic ulcer disease; avoid in pheochromocytoma
- Evidence: Earlier studies suggested 56% reduction in vertigo compared to placebo, but the high-quality BEMED trial found no significant difference 2
Symptomatic medications during acute attacks
- Antivertigo medications
- Antiemetics
- Antihistamines
Second-Line Treatment Options (For Refractory Cases)
Intratympanic Interventions
Intratympanic steroids
- Indicated for: Active Meniere's disease not responsive to noninvasive treatments
- Benefits: Improved vertigo control, quality of life, faster return to work
- Risks: Hearing loss, eardrum perforation, persistent imbalance 2
Intratympanic gentamicin
- Mechanism: Reduces vestibular function in the treated ear
- Note: Complete ablation of vestibular function is not typically required for vertigo control
- Best used for: Patients with persistent vertigo despite medical management 3
Surgical Options (Based on Hearing Status)
For patients with usable hearing:
- Endolymphatic sac decompression: Reduces endolymphatic pressure 2
For patients with non-serviceable hearing:
- Vestibular nerve section: Severs the vestibular portion of cranial nerve VIII
- Labyrinthectomy: Removes the labyrinth, controlling vertigo but sacrificing remaining hearing 2
Treatment Considerations
Hearing Management
- Hearing aids for patients with hearing loss
- Cochlear implantation may be considered in advanced cases with profound hearing loss 4
Vestibular Rehabilitation
- Beneficial for chronic imbalance between attacks
- Not recommended during acute vertigo attacks 2
Monitoring and Follow-up
- Regular audiologic and vestibular assessment to monitor disease progression
- Consider tapering or stopping medication once symptoms subside 2
Special Considerations
Bilateral Disease (10-25% of cases)
- Requires caution with ablative procedures to avoid total vestibular loss
- Corticosteroids may be particularly beneficial if autoimmune basis is suspected 5
Patient Education
- Provide verbal and written information about the disease course
- Set realistic expectations: There is no cure, only symptom management
- Address quality of life impact, including psychological aspects such as anxiety and depression 2
Treatment Pitfalls to Avoid
- Overreliance on single therapy - A combination approach is often more effective
- Premature progression to invasive treatments - Exhaust conservative options first
- Neglecting psychological impact - Address anxiety and depression that commonly accompany the condition
- Ignoring bilateral potential - Monitor the unaffected ear as 10-25% of cases become bilateral
- Meniett device - Not recommended as systematic reviews show no significant difference in vertigo control compared to placebo 2
Remember that Meniere's disease has a variable natural course with spontaneous remissions, making treatment efficacy assessment challenging. Up to 60% of patients in placebo groups of clinical trials report vertigo control, highlighting the importance of controlled studies when evaluating treatments 1.