What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

The treatment of Meniere's disease should follow a stepwise approach, beginning with lifestyle modifications and vestibular suppressants for acute attacks, progressing to maintenance therapy with diuretics and/or betahistine, and considering more invasive interventions only for refractory cases. 1

First-Line Management

Acute Attack Management

• Vestibular suppressants should be offered as first-line therapy for acute vertigo attacks 2, 1
  • Includes benzodiazepines and antiemetics
  • Should be used for a limited course only
  • Caution: Risk of dependence, sedation, and impaired vestibular compensation

Lifestyle Modifications

• Low-sodium diet (1500-2300 mg daily) 1
• Limit alcohol and caffeine intake 1, 3
• Stress management 1
• Consider keeping a food diary to identify personal triggers 1
• Adequate sleep in darkness 1

Second-Line Management

Maintenance Pharmacotherapy

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

  • Options include thiazides, potassium-sparing diuretics, and loop diuretics
  • Note: High-quality evidence supporting efficacy is limited 4

• Betahistine may be considered at dosages of 16-48 mg daily 2, 1

  • Caution in patients with asthma or peptic ulcer disease
  • Note: Evidence for efficacy is limited per Cochrane review 4

Third-Line Management

Intratympanic Therapies

• Intratympanic steroid injections for persistent symptoms 1

  • Can improve vertigo symptoms in 85-90% of cases compared to 57-80% with conventional therapy
  • May be considered in combination with betahistine for enhanced efficacy

• Intratympanic gentamicin for refractory vertigo 1, 5, 6

  • Achieves complete vertigo control in approximately 73.6% of patients
  • Important caveat: Carries a 25.1% risk of hearing loss
  • Contraindicated in patients with contralateral disease or aminoglycoside hypersensitivity

Rehabilitation

• Vestibular rehabilitation/physical therapy should be offered for patients who have failed less definitive therapy and have nonusable hearing 2
• Beneficial for chronic imbalance between attacks 1

Fourth-Line Management (Surgical Options)

For patients with severe, refractory disease:

• Endolymphatic sac surgery when hearing preservation is important 5
• Vestibular nerve section as a hearing-sparing procedure 1
• Labyrinthectomy for cases with profound hearing loss 1, 5
  • May be combined with cochlear implantation in appropriate cases

Important Considerations

Monitoring and Assessment

• Obtain an audiogram when assessing a patient for Meniere's disease 2
• Regular audiologic assessment to monitor disease progression 1
• Document baseline severity of vertigo, tinnitus, and hearing loss 1
• Schedule regular follow-ups to assess symptom improvement or worsening 1

Patient Education

• Counsel patients about the natural history, measures for symptom control, treatment options, and outcomes 2
• Provide both verbal and written information about the disease 1
• Address psychological aspects such as anxiety, depression, and social isolation 1
• Set realistic expectations: there is no cure, only symptom management 1

Therapies to Avoid

• Do not prescribe positive pressure therapy (Meniett device) as systematic reviews show no significant benefit over placebo 2, 1

Special Considerations

• 10-25% of patients develop bilateral Meniere's disease over time, which impacts treatment decisions regarding ablative therapies 1
• Consider hearing aids for patients with hearing loss 1
• Support groups can provide valuable resources and emotional support 1

The management of Meniere's disease requires a stepwise approach with careful consideration of symptom severity, hearing status, and impact on quality of life. While there is no cure, appropriate management can significantly improve symptoms and quality of life for most patients.