What is the initial management for a patient with a history of Ménière’s disease and persistent vertigo?

Initial Management of Persistent Vertigo in Ménière's Disease

For patients with Ménière's disease and persistent vertigo, the initial management should include a limited course of vestibular suppressants along with lifestyle modifications focusing on sodium restriction (1500-2300 mg daily). 1

Step-by-Step Initial Management Approach

1. Symptomatic Relief for Acute Vertigo Attacks

• Vestibular suppressants should be offered as first-line therapy for acute vertigo attacks 1
  • Meclizine 25-100 mg daily in divided doses 2
  • Benzodiazepines (with caution due to dependence risk)
  • Antiemetics for associated nausea
  • Important: Limit vestibular suppressants to acute attacks only, as prolonged use can delay central compensation 3

2. Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) 1, 3
• Limit alcohol consumption 3
• Limit caffeine intake 3
• Stress management 3
• Adequate sleep in darkness 3
• Consider allergy management if applicable 3

3. Maintenance Pharmacotherapy

• Diuretics may be offered to reduce endolymph volume 1, 3
  • Options include thiazides, potassium-sparing diuretics, loop diuretics
• Betahistine may be considered (16-48 mg daily in divided doses) 1, 3
  • Caution: Use with care in patients with asthma or peptic ulcer disease
  • Note: High-quality evidence for efficacy is limited

Audiometric Monitoring

• Obtain an audiogram when assessing a patient with Ménière's disease 1
• Regular audiologic assessment is necessary to monitor disease progression 3

Patient Education

• Counsel patients about the natural history of Ménière's disease 1
• Explain that there is no cure, only symptom management 3
• Discuss treatment expectations and potential long-term effects 3

When Initial Management Fails

If persistent vertigo continues despite the above measures:

1. Intratympanic steroids may be offered for active Ménière's disease not responsive to initial therapy 1, 3

2. Intratympanic gentamicin should be offered for patients with active Ménière's disease not responsive to non-ablative therapy 1, 4, 5

   • Reduces vestibular function in the treated ear
   • Goal is to control vertigo while preserving hearing function
   • Note: Complete ablation of vestibular function is not typically required to achieve control of vertigo 5

3. Vestibular rehabilitation/physical therapy should be offered for patients who have failed less definitive therapy and have nonusable hearing 1

   • Beneficial for chronic imbalance between attacks
   • Caution: Not recommended during acute vertigo attacks

Important Considerations and Pitfalls

• Avoid positive pressure therapy (Meniett device) as it is not recommended for Ménière's disease 1, 3

• Rule out vestibular migraine when assessing for Ménière's disease, as the conditions can coexist or be confused 1, 6

• Be cautious with ablative procedures if bilateral disease is suspected (occurs in 10-25% of cases over time) to avoid total vestibular loss 3

• Monitor for medication side effects:

  • Anticholinergic effects with meclizine (use with caution in patients with asthma, glaucoma, or prostate enlargement) 2
  • CNS depression with vestibular suppressants, especially when combined with alcohol 2

• Consider hearing aids for patients with significant hearing loss 3, 6