What are the treatment options for Meniere's disease?

Treatment for Meniere's Disease

The American Academy of Otolaryngology-Head and Neck Surgery recommends a stepwise approach to treating Meniere's disease, starting with dietary and lifestyle modifications, followed by pharmacotherapy with diuretics and/or betahistine, and progressing to more invasive treatments like intratympanic steroids only if necessary. 1

First-Line Treatment: Dietary and Lifestyle Modifications

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

Pharmacotherapy for Acute Vertigo Attacks

• Offer a limited course of vestibular suppressants only during acute vertigo episodes 1
• Use antihistamines such as dimenhidrinato or meclizine for symptomatic relief 1
• Consider short-term benzodiazepines to manage associated anxiety, with caution due to dependence risk 1

Maintenance Therapy

• Diuretics are recommended to alter electrolyte balance in the endolymph and reduce its volume 2, 1
• Betahistine (a histamine analog) may be offered to increase inner ear vasodilation, though recent evidence from the BEMED trial questions its efficacy compared to placebo 2, 1

Second-Line Treatments: 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 1
  • Potential risks include hearing loss, tympanic membrane perforation, and persistent imbalance 1

• Intratympanic gentamicin can be effective for persistent vertigo that has failed conservative therapies 1

  • Achieves complete vertigo control in approximately 73.6% of cases 1
  • Carries risk of hearing loss that varies by administration method 1

Surgical Options for Refractory Cases

• Surgical interventions should be considered only after failure of less invasive approaches 1
• Endolymphatic sac decompression (with or without shunt placement) is recommended as the first surgical option for patients who fail medical therapy 3
• Ablative procedures such as labyrinthectomy may be offered to patients with non-usable hearing who have failed less definitive therapy 1
• Vestibular neurectomy is another ablative option that can control episodic vertigo 3

Treatments Not Recommended

• The American Academy of Otolaryngology-Head and Neck Surgery recommends against positive pressure therapy (Meniett device) based on systematic reviews showing no significant benefit compared to placebo 2, 1
• Vestibular rehabilitation/physical therapy is not recommended for acute vertigo attacks but may help manage chronic imbalance between episodes 1

Important Considerations and Monitoring

• No definitive cure exists for Meniere's disease 1
• Scientific evidence for many interventions, especially dietary modifications, remains limited 1
• Consider comorbidities that may contraindicate certain medications (e.g., renal or cardiac disease, asthma) 1
• Systematically document symptom changes (vertigo, tinnitus, hearing loss) after treatment and adjust therapy accordingly 1
• Without treatment, hearing may deteriorate over 10+ years as vertiginous episodes gradually subside 4