What is the initial treatment for Meniere's disease?

Initial Treatment for Meniere's Disease

Begin with dietary modifications—specifically sodium restriction to 1500-2300 mg daily—combined with lifestyle changes including limitation of alcohol and caffeine, as this represents the first-line, least invasive approach recommended by the American Academy of Otolaryngology-Head and Neck Surgery. 1

First-Line Conservative Management

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce fluid accumulation in the inner ear and potentially stabilize endolymphatic hydrops 1, 2
• Eliminate or significantly reduce alcohol consumption, as it can trigger vertigo attacks in susceptible patients 1, 3
• Limit caffeine intake, which may precipitate symptoms in certain individuals 1, 3
• Identify and manage allergies, as they contribute to symptoms in approximately 30% of patients 1
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep 1
• Maintain a symptom diary to identify personal triggers and patterns 1

These modifications are universally recommended as initial therapy despite limited high-quality evidence, based on their safety profile and potential benefit 4, 3. The rationale is that reducing sodium intake may decrease endolymphatic fluid volume, though the exact mechanism remains incompletely understood 5, 6.

Pharmacotherapy for Acute Attacks

Symptomatic Relief During Vertigo Episodes

• Offer vestibular suppressants only during acute vertigo attacks, not for continuous use 1
• Antihistamines (dimenhidrinato, meclizina) are effective for acute symptom control 1, 5
• Benzodiazepines may be used cautiously for associated anxiety during attacks, but avoid prolonged use due to dependence risk 1, 5

Critical caveat: Vestibular suppressants should be limited to acute episodes only, as continuous use can interfere with central compensation mechanisms 7, 1.

Maintenance Pharmacotherapy

Diuretics

• Diuretics are recommended to alter electrolyte balance in the endolymph and reduce its volume 1, 2
• The American Academy of Otolaryngology-Head and Neck Surgery supports diuretic use, though studies have varied widely in duration (10 days to 24 years) 7
• Titrate down or discontinue diuretics once symptoms subside 7

Betahistine

• Betahistine (a histamine analogue) increases vasodilation to the inner ear and may reduce attack frequency 1, 8
• However, the most recent high-quality evidence (BEMED trial) found no significant difference between betahistine and placebo in reducing vertigo attacks, making its routine use questionable 1

This represents an important divergence in the evidence: while betahistine is widely used in Europe and mentioned in multiple guidelines 5, 8, the most recent rigorous trial does not support its efficacy 1. Given this contradiction, diuretics represent a more evidence-supported maintenance option.

Algorithmic Approach to Initial Treatment

1. Start all patients with dietary sodium restriction (1500-2300 mg/day) plus alcohol and caffeine limitation 1, 3
2. Add diuretics for maintenance therapy if attacks continue despite dietary modifications 7, 1
3. Provide vestibular suppressants and antihistamines for use during acute attacks only 1
4. Consider betahistine as an adjunct with patient counseling about limited evidence for efficacy 1
5. Reassess after 2-3 months: if symptoms persist despite optimal medical management, consider intratympanic steroids 1

Important Clinical Pitfalls

• Do not use vestibular suppressants continuously—they should only be prescribed for acute episodes to avoid interfering with vestibular compensation 7, 1
• Avoid benzodiazepines for chronic management due to dependence risk; reserve for acute anxiety during attacks 1
• Do not recommend positive pressure therapy (Meniett device)—systematic reviews show no benefit over placebo, and it may worsen hearing 7, 1
• Regular audiometric testing is essential to monitor hearing progression, as hearing loss often worsens despite treatment 2, 8
• Document symptom evolution systematically (vertigo frequency, hearing changes, tinnitus, quality of life impact) to guide treatment adjustments 1, 2

When to Escalate Treatment

If patients fail to respond to 2-3 months of optimal conservative management (dietary modifications plus diuretics), escalate to intratympanic steroids, which show 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy alone 1. This represents the next step before considering more invasive surgical options 1, 8.