What medication would you recommend for a 48-year-old woman with episodic vertigo, tinnitus, and mild hearing loss in the right ear, with normal vitals and intact tympanic membranes?

Medication Management for Meniere's Disease

For a 48-year-old woman with episodic vertigo, tinnitus, and mild hearing loss in the right ear consistent with Meniere's disease, meclizine should be offered as first-line therapy for acute vertigo attacks, with betahistine as maintenance therapy to reduce the frequency and severity of episodes. 1, 2

First-Line Treatment Approach

Acute Attack Management:

• Meclizine (25-50 mg) is FDA-approved for treating vertigo associated with vestibular system diseases 1
  • Administer during acute vertigo episodes
  • Can be taken as needed when symptoms begin
  • Monitor for sedation and advise against driving or operating machinery

Maintenance Therapy:

• Betahistine (16-48 mg daily, divided doses) should be initiated to reduce the frequency and severity of vertigo attacks 2
  • Mechanism: Weak H1 receptor agonist and more potent H3 receptor antagonist that improves microcirculation in the inner ear 3
  • Multiple studies demonstrate efficacy in reducing vertigo attack frequency, severity, and duration 4, 5
  • Use with caution in patients with asthma or peptic ulcer disease 6

Additional Management Considerations

Lifestyle Modifications:

• Low-sodium diet (1500-2300 mg daily)
• Limit alcohol and caffeine intake
• Stress management techniques
• Regular sleep patterns 2

Second-Line Options:

• Diuretics may be considered if betahistine is ineffective:
  • Hydrochlorothiazide (25 mg daily) can help reduce endolymph volume 2, 7
  • May be particularly effective in patients with stable hearing thresholds 7

Refractory Disease Management:

• Intratympanic steroid injections if symptoms persist despite oral medications 6

  • 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy
  • Consider combination with betahistine for enhanced efficacy (73% vs 44% control) 6

• Intratympanic gentamicin for severe refractory cases 6, 2

  • Complete vertigo control in approximately 73.6% of patients
  • Risk of hearing loss (25.1% overall) must be discussed with patient
  • Contraindicated in patients with contralateral disease or known hypersensitivity to aminoglycosides 6

Monitoring and Follow-up

• Schedule regular follow-up visits to assess symptom improvement
• Obtain serial audiograms to monitor hearing function
• Assess treatment efficacy after 6-8 weeks
• Consider titrating down or stopping medication once symptoms subside 6

Important Caveats

• Avoid positive pressure therapy (Meniett device) as systematic reviews show no significant benefit over placebo 6, 2
• Use benzodiazepines cautiously due to risk of dependence, sedation, and impaired vestibular compensation 2
• Consider vestibular rehabilitation for chronic imbalance between attacks 2
• Approximately 10-25% of patients develop bilateral Meniere's disease over time, which impacts treatment decisions 2

While the evidence for betahistine has some limitations, the most recent guidelines and clinical studies support its use for reducing the frequency and severity of Meniere's attacks, with a favorable safety profile over long-term use 4, 8. Meclizine remains the most appropriate FDA-approved medication for acute symptom control 1.