Management of Meniere's Disease
The management of Meniere's disease should follow a stepwise approach, starting with dietary and lifestyle modifications, followed by pharmacotherapy, and progressing to more invasive treatments only when necessary. 1
Diagnosis
- Clinicians should diagnose definite or probable Meniere's disease in patients presenting with 2 or more episodes of vertigo lasting 20 minutes to 12 hours (definite) or up to 24 hours (probable) and fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear 2
- An audiogram should be obtained when assessing a patient for the diagnosis of Meniere's disease 2
- MRI of the internal auditory canal may be offered in patients with nonfluctuating sensorineural hearing loss, tinnitus, or pressure when symptoms are not better explained by another disorder 2
First-Line Management: Lifestyle and Dietary Modifications
- Sodium restriction (1500-2300 mg daily) is recommended to reduce endolymphatic fluid accumulation 1
- Limitation of alcohol consumption is recommended as it may trigger attacks 1
- Limitation of caffeine intake is recommended as it may be a trigger for some patients 1
- Identification and management of allergies is important, as they may contribute to symptoms in up to 30% of patients 1
- Stress management through relaxation techniques, regular exercise, and adequate sleep is recommended 1
- Maintaining a symptom diary helps identify personal triggers 1
Pharmacotherapy for Acute Attacks
- A limited course of vestibular suppressants should be offered only during acute Meniere's attacks 2
- Options include antihistamines (dimenhidrinato, meclizine) for symptom control 1
- Benzodiazepines may be used with caution to alleviate associated anxiety, considering the risk of dependence 1
Maintenance Therapy
- Diuretics may be offered to alter electrolyte balance in the endolymph, reducing its volume 1, 3
- Betahistine may be offered as maintenance therapy to reduce symptoms or prevent attacks 1, 3
- Recent evidence from the BEMED trial has questioned betahistine's efficacy, showing no significant difference between betahistine and placebo in reducing vertigo attacks 1
Second-Line Interventions: Intratympanic Therapies
Intratympanic steroids may be offered to patients with active Meniere's disease not responsive to non-invasive treatments 2, 1
Intratympanic gentamicin should be offered to patients with active Meniere's disease not responsive to nonablative therapy 2, 1
Surgical Options for Refractory Cases
- Surgical options for cases refractory to medical treatment include both hearing-preserving procedures and ablative procedures 1
- Labyrinthectomy may be offered to patients with active Meniere's disease who have failed less definitive therapy and have non-usable hearing 1
- Endolymphatic sac decompression surgery has shown overall relief of vertigo in 71% of patients 4
Vestibular Rehabilitation
- Vestibular rehabilitation/physical therapy should be offered for patients with Meniere's disease who have failed less definitive therapy and have nonusable hearing 2
- Not recommended for management of acute vertigo attacks, but useful for chronic imbalance between attacks 1
Treatments Not Recommended
- Positive pressure therapy (Meniett device) should not be prescribed for patients with Meniere's disease 2, 1
- Routine vestibular function testing or electrocochleography is not recommended to establish the diagnosis 2
Follow-Up and Monitoring
- Clinicians should document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss 2, 3
- Regular assessment of quality of life changes is essential 2, 3
- Treatment should be adjusted based on symptom evolution 1
Important Considerations
- There is no definitive cure for Meniere's disease 1
- Scientific evidence for many interventions, especially dietary modifications, is limited 1
- Consider comorbidities that may contraindicate certain medications (kidney or heart disease, asthma) 1, 3
- Use benzodiazepines with caution due to the risk of dependence 1