What are the treatment options for outpatient management of Meniere's disease?

Outpatient Management of Meniere's Disease

The first-line outpatient treatment for Meniere's disease includes vestibular suppressants for acute attacks, lifestyle modifications (particularly sodium restriction), and maintenance therapy with diuretics and/or betahistine. 1, 2

Acute Attack Management

• Vestibular suppressants should be offered as first-line therapy for acute vertigo attacks 2:
  • Benzodiazepines (e.g., alprazolam)
  • Antiemetics
  • Caution: Risk of dependence, sedation, and impaired vestibular compensation 1
  • Use for shortest duration necessary to control symptoms

Lifestyle and Dietary Modifications

• Low-sodium diet (1500-2300 mg daily) 2, 3

  • Consider keeping a food diary to identify personal triggers 2
  • Despite widespread recommendation, high-quality evidence from RCTs is lacking 4

• Additional dietary modifications:

  • Limit caffeine and alcohol intake 2, 3
  • Some patients may benefit from gluten-free diet 3

• Cooling measures for symptom relief:

  • Limit ice or water immersion (e.g., 10 minutes, 4 times daily) to avoid tissue damage 1
  • Elevation of extremities may help during symptom flares 1

Maintenance Pharmacotherapy

• Diuretics may be offered to reduce endolymph volume 1, 2:

  • Thiazides (e.g., hydrochlorothiazide)
  • Potassium-sparing diuretics
  • Loop diuretics
  • Note: Consider as second-line therapy after vestibular suppressants 2

• Betahistine (16-48 mg daily) 2, 5:

  • May be more effective than hydrochlorothiazide for patients with fluctuating auditory threshold 5
  • Use with caution in patients with asthma or peptic ulcer disease 2
  • Note: Not FDA-approved in the US but widely used in Europe 6

Procedural Interventions (for refractory cases)

• Intratympanic steroid injections for persistent symptoms despite medical management 2

• Intratympanic gentamicin may be considered for vertigo control in refractory cases 2

  • Caution: Risk of hearing loss

• Surgical options for severe refractory cases:

  • Vestibular nerve section (hearing-sparing procedure) 2
  • Labyrinthectomy (for cases with profound hearing loss) 2

Rehabilitation and Support

• Vestibular rehabilitation (physical therapy) for chronic imbalance between attacks 2

• Hearing aids for patients with hearing loss 2

• Patient education about:

  • Natural history of disease
  • Symptom management strategies
  • Treatment options and expectations
  • Quality of life impact 1, 2

Important Considerations

• Do NOT prescribe positive pressure therapy (e.g., Meniett device) as evidence shows ineffectiveness 1

• Monitor disease progression with:

  • Regular audiologic assessment
  • Documentation of vertigo frequency and severity
  • Quality of life assessment 2

• Rule out vestibular migraine as it can coexist with or mimic Meniere's disease 2

• Consider multidisciplinary approach for patients with severe, refractory, or disabling symptoms 1

The management of Meniere's disease should focus on controlling acute attacks while implementing strategies to reduce the frequency and severity of future episodes. While many treatments are recommended based on clinical experience rather than high-quality evidence, a structured approach using vestibular suppressants for acute attacks and lifestyle modifications with maintenance medications for prevention represents the current standard of care.