What are the treatment options for Meniere's disease?

Treatment for Meniere's Disease

Begin with dietary modifications (sodium restriction to 1500-2300 mg daily, limiting caffeine and alcohol) combined with patient education, then escalate to diuretics and/or betahistine for maintenance therapy, reserving intratympanic steroids for patients who fail non-invasive treatment. 1, 2

Initial Management: Lifestyle and Dietary Modifications

Start all patients with dietary and lifestyle changes as first-line therapy, even though the evidence base is limited (Grade C), because these interventions carry minimal risk and may prevent progression to more invasive treatments. 1, 2

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear. 1, 2
• Limit or eliminate caffeine consumption, as it can trigger attacks in susceptible patients. 1, 2
• Restrict alcohol intake, which may precipitate vertiginous episodes. 2, 3
• Encourage patients to maintain a symptom diary to identify personal triggers and patterns, which empowers patients and guides individualized management. 2
• Address allergies if present, as they contribute to symptoms in up to 30% of patients with Meniere's disease. 2
• Implement stress management techniques including relaxation exercises, regular physical activity, and adequate sleep. 2

Common pitfall: While sodium restriction is widely recommended, one small RCT showed no benefit, though it had significant study limitations. Despite weak evidence, the risk-benefit ratio favors this intervention given its safety profile and potential to avoid more invasive therapies. 1

Patient Education (Essential Component)

Provide comprehensive education about the natural history, symptom control measures, treatment options, and realistic outcomes at the initial visit. 1

• Explain that no definitive cure exists, but symptoms can be managed effectively in most patients. 2
• Discuss the fluctuating nature of symptoms, particularly hearing loss, which may initially improve but typically progresses over time despite treatment. 4
• Emphasize that most patients improve significantly within 2 years of treatment, which helps set realistic expectations. 5
• Utilize shared decision-making to involve patients in choosing among treatment options based on their preferences and symptom severity. 1

Acute Vertigo Attack Management

Offer a limited course of vestibular suppressants only during active vertigo attacks, not for continuous use. 1

• Antihistamines (meclizine, dimenhydrinate) are first-line agents for acute vertigo control. 2
• Benzodiazepines may be added to manage associated anxiety during severe attacks, but use cautiously due to dependence risk. 2
• Antiemetics can be prescribed for nausea and vomiting during attacks. 5

Critical caveat: Do not prescribe vestibular suppressants for chronic use, as they impair vestibular compensation and may worsen long-term balance function. 1

Maintenance Pharmacotherapy

Offer diuretics and/or betahistine for ongoing symptom prevention after initial lifestyle modifications have been implemented. 1, 2

• Diuretics (typically thiazides) alter electrolyte balance in the endolymph, reducing its volume and potentially decreasing attack frequency. 1, 2
• Betahistine (a histamine analogue) increases vasodilation to the inner ear, though recent evidence including the BEMED trial questions its efficacy compared to placebo. 2, 4
• Consider comorbidities before prescribing: avoid diuretics in patients with renal or cardiac disease; use caution with betahistine in asthma patients. 1

Evidence conflict: While betahistine is widely used in Europe and recommended as an option by the American Academy of Otolaryngology-Head and Neck Surgery, the most recent BEMED trial found no significant difference from placebo in reducing vertigo attacks. 2 Given this equipoise, betahistine remains an option but should not be considered definitive therapy.

Intratympanic Therapies (Second-Line)

Offer intratympanic steroids to patients with active disease not responding to non-invasive treatments. 1, 2

• Intratympanic corticosteroids show 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy alone. 2
• Benefits include improved vertigo control, better quality of life, faster return to work, and avoidance of general anesthesia. 1
• Risks include hearing loss, tympanic membrane perforation, persistent imbalance, and need for multiple treatments. 1

For patients who fail intratympanic steroids, consider intratympanic gentamicin, which achieves complete vertigo control in approximately 73.6% of cases but carries variable risk of hearing loss depending on administration protocol. 2

Important consideration: Reserve intratympanic gentamicin for patients with non-usable hearing or those who have exhausted other options, as it works through chemical ablation of vestibular function. 2

Surgical Options (Third-Line)

Reserve surgical interventions for patients with severe, refractory symptoms despite maximal medical therapy. 2, 6

• Endolymphatic sac decompression is a hearing-preserving procedure that may stabilize symptoms and should be considered first among surgical options. 4, 6
• Vestibular nerve section provides vertigo control while preserving hearing. 4
• Labyrinthectomy (surgical or chemical) sacrifices all remaining hearing but effectively controls vertigo in patients with non-usable hearing. 2, 4

Treatments NOT Recommended

Do not prescribe positive pressure therapy (Meniett device), as systematic reviews and RCTs demonstrate no benefit over placebo. 1, 2

Do not use vestibular rehabilitation therapy for acute vertigo attacks, though it may help with chronic imbalance between episodes. 2

Hearing Rehabilitation

Address progressive hearing loss with appropriate amplification strategies as the disease evolves. 4

• Conventional hearing aids for patients with usable hearing and adequate speech discrimination. 4
• CROS hearing aids when speech discrimination is severely compromised. 4
• Cochlear implants for patients with severe bilateral hearing loss where amplification provides limited benefit, even after ablative procedures. 4

Monitoring and Follow-Up

Document systematically the resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention. 2

• Perform regular audiometric testing to track hearing progression and guide treatment decisions. 4
• Assess quality of life impact at each visit to determine if treatment escalation is warranted. 2, 4
• Adjust treatment based on symptom evolution, recognizing that most patients show marked improvement within 2 years but hearing loss often progresses despite treatment. 4, 5