What are the treatments for Meniere's disease?

Treatments for Meniere's Disease

The treatment of Meniere's disease follows a stepwise approach, beginning with lifestyle modifications and medical management, progressing to intratympanic therapies, and finally to surgical interventions when conservative measures fail. 1

First-Line Treatments: Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) is recommended to reduce endolymphatic pressure and symptom frequency 1, 2
• Limit alcohol and caffeine intake to reduce trigger factors 1, 2
• Stress management techniques to minimize attack triggers 1
• Allergy management when relevant 1
• Adequate sleep and exercise to improve overall symptom control 1
• Support groups to help with psychological aspects of the disease 1

Medical Management

Acute Attack Management

• Vestibular suppressants (benzodiazepines, anticholinergics) should be used ONLY during acute attacks due to risk of dependence 1
• Antiemetics to control nausea and vomiting during attacks 1
• Antihistamines may provide symptomatic relief 1

⚠️ Caution: Prolonged use of vestibular suppressants delays central compensation and should be strictly limited to acute attacks 1

Preventive Medications

• Diuretics (thiazides, potassium-sparing diuretics, loop diuretics, carbonic anhydrase inhibitors) to reduce endolymph volume 1
• Betahistine (16-48 mg daily in divided doses) - commonly used in Europe and recommended by international consensus 1, 3
  • Use with caution in patients with asthma or peptic ulcer disease
  • Avoid in patients with pheochromocytoma
  • Note: Recent high-quality trials show mixed efficacy results 1
• Local pressure therapy (Meniett device) - though systematic reviews show no significant difference compared to placebo 1, 3

Second-Line Treatment

• Intratympanic steroid injections when first-line treatments fail 1, 3
  • Benefits: Improved vertigo control, quality of life, faster return to work
  • Risks: Eardrum perforation, persistent imbalance

Third-Line Treatments (Based on Hearing Status)

For Patients with Serviceable Hearing

• Endolymphatic sac decompression surgery to reduce endolymphatic pressure 1, 3
• Vestibular rehabilitation/physical therapy for chronic imbalance between attacks (not during acute episodes) 1

For Patients with Poor Hearing

• Intratympanic gentamicin to reduce vestibular function in the affected ear 1, 3, 4
  • Modern low-dose protocols aim to control vertigo while minimizing hearing loss risk
  • Most effective for persistent vertigo despite medical management

Last-Resort Surgical Options

• Vestibular nerve section for patients with serviceable hearing who have failed other treatments 1, 3
• Labyrinthectomy for patients with non-serviceable hearing, controlling vertigo but sacrificing remaining hearing 1, 3
• Cochlear implantation may be considered in conjunction with labyrinthectomy for profound hearing loss 3

Patient Education and Monitoring

• Provide verbal and written information about the disease course and treatment options 1
• Set realistic expectations (symptom management, not cure) 1
• Regular audiologic and vestibular assessment to monitor disease progression 1
• Consider hearing aids for patients with significant hearing loss 1

Treatment Algorithm

1. Start with lifestyle modifications and dietary changes
2. Add preventive medications (diuretics and/or betahistine)
3. For persistent symptoms, proceed to intratympanic steroid injections
4. If symptoms persist, choose based on hearing status:
   • Good hearing: Endolymphatic sac surgery
   • Poor hearing: Intratympanic gentamicin
5. For refractory cases, consider destructive procedures based on hearing status