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, starting with lifestyle modifications and progressing to pharmacotherapy, intratympanic therapies, and surgical interventions only when necessary. 1

First-Line Treatments: Lifestyle and Dietary Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce fluid accumulation in the inner ear 1
• Limit alcohol consumption as it can trigger attacks in susceptible patients 1
• Reduce caffeine intake which may act as a symptom trigger 1
• Identify and manage allergies, which may contribute to symptoms in up to 30% of patients 1
• Implement stress management techniques including relaxation, regular exercise, and adequate sleep 1
• Maintain a symptom diary to identify personal triggers 1

Acute Attack Management

• Offer short-term vestibular suppressants only during acute vertigo attacks 1
• Use antihistamines such as dimenhidrinato or meclizine for symptomatic relief 1
• Consider benzodiazepines for associated anxiety, but use cautiously due to dependency risk 1

Maintenance Pharmacotherapy

• Diuretics are recommended to alter electrolyte balance in the endolymph and reduce its volume 1
• Betahistine's efficacy is questionable based on recent evidence:
  • The 2020 American Academy of Otolaryngology-Head and Neck Surgery guideline cannot make a definitive recommendation for betahistine 2, 3
  • The BEMED trial found no significant difference between betahistine (at either low 48 mg/day or high 144 mg/day doses) and placebo in reducing vertigo attacks 2, 3
  • If prescribed, monitor for side effects including headache, nausea, and gastrointestinal symptoms 3
  • Contraindicated in patients with pheochromocytoma and should be used cautiously in those with asthma or peptic ulcer disease 3

Intratympanic Therapies

• Intratympanic steroids may be offered to patients with active Meniere's disease not responsive to non-invasive treatments 2

  • Studies show 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy 2
  • One study found improved efficacy when combined with oral betahistine (73% vs 44% control) 2

• Intratympanic gentamicin is effective for vertigo control in patients who have failed conservative therapies 2

  • Complete vertigo control rate of approximately 73.6% across studies 2
  • Titration therapy showed better control (81.7%) compared to low-dose methods (66.7%) 2
  • Risk of hearing loss varies by administration method: weekly titration (13.1%), multiple daily dosing (34.7%), with overall average of 25.1% 2
  • Profound hearing loss occurs in approximately 6.6% of cases regardless of delivery method 2
  • Contraindicated in patients with bilateral disease or vestibular hypofunction 2

Surgical Options

• Labyrinthectomy may be offered to patients with active Meniere's disease who have failed less definitive therapy and have non-usable hearing 2
• Surgical interventions should be considered only after failure of medical management 1, 4

Treatments Not Recommended

• Positive pressure therapy (Meniett device) is not recommended based on systematic reviews showing no significant difference compared to placebo 2, 1
• Vestibular rehabilitation is not recommended for acute attacks but may help with chronic imbalance between episodes 1

Important Considerations

• No definitive cure exists for Meniere's disease 1
• Treatment efficacy should be monitored through documentation of symptom changes and quality of life impact 1
• Bilateral involvement occurs in 25-40% of cases, which may affect treatment decisions, particularly regarding ablative therapies 4
• Without treatment, hearing may deteriorate over 10+ years as vertiginous episodes gradually subside 5