What are the treatment options for Meniere's disease?

Treatment Options for Ménière's Disease

Begin with patient education, dietary modifications (sodium restriction to 1500-2300 mg/day, limiting caffeine and alcohol), and consider diuretics or betahistine for maintenance therapy; escalate to intratympanic steroids for active disease unresponsive to conservative measures, and reserve intratympanic gentamicin or surgical ablation for refractory cases with severe vertigo. 1, 2

Initial Conservative Management

Patient Education (Essential First Step)

• Educate all patients about the natural history, symptom control measures, treatment options, and expected outcomes to improve quality of life and enable shared decision-making 1
• Encourage patients to maintain a symptom diary to identify personal triggers for attacks 2

Dietary and Lifestyle Modifications

• Sodium restriction to 1500-2300 mg daily is recommended to reduce endolymphatic fluid accumulation, though evidence quality is Grade C based on limited RCT data 1, 2
• Limit caffeine intake, as observational studies show benefit from caffeine restriction 1, 2
• Limit alcohol consumption, which can trigger attacks in susceptible patients 2, 3
• Identify and manage allergies, as they may contribute to symptoms in up to 30% of patients 2
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep 2

Important caveat: While dietary modifications are first-line treatment, evidence is limited (Grade C), and some panel members expressed concern about hyponatremia risk with sodium restriction, though this has not been reported in studies and can be minimized with proper nutritional counseling 1

Acute Attack Management

Vestibular Suppressants (During Attacks Only)

• Offer a limited course of vestibular suppressants only during acute vertigo attacks lasting 20 minutes to 12 hours 1, 2
• Options include antihistamines (dimenhidrinato, meclizine) 2
• Benzodiazepines may be used cautiously for associated anxiety, but avoid prolonged use due to dependence risk and impaired vestibular compensation 1, 2

Critical warning: Do not use vestibular suppressants for maintenance therapy, as they can impair vestibular compensation 1

Maintenance Pharmacotherapy

Diuretics and Betahistine

• Diuretics may be offered for maintenance therapy to modify electrolyte balance in the endolymph and reduce its volume (Grade C evidence from observational studies and Cochrane reviews) 1, 2
• Betahistine may be offered as a histamine analogue that increases inner ear vasodilation 1, 2

Important limitation: Recent evidence from the BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks, making the recommendation for betahistine questionable 2

Contraindications: Avoid in patients with renal or cardiac disease, asthma, or medication allergies 1

Escalation to Invasive Therapies

Intratympanic Steroids (Second-Line)

• Offer intratympanic steroids to patients with active Ménière's disease not responsive to non-invasive treatment (Grade B evidence from RCTs and systematic reviews) 1, 2
• Benefits include 85-90% improvement in vertigo symptoms (vs. 57-80% with conventional therapy), improved quality of life, and faster return to work 1, 2
• Risks include hearing loss, tympanic membrane perforation, persistent imbalance, and need for multiple treatments 1, 2

Intratympanic Gentamicin (Third-Line)

• Offer intratympanic gentamicin to patients with persistent vertigo who have failed conservative therapies 2
• Achieves complete vertigo control in approximately 73.6% of patients across studies 2
• Significant risk of hearing loss varies by administration method; contraindicated in patients with contralateral disease or hypofunction 1, 2

Surgical Options (Refractory Cases)

Ablative Procedures

• Labyrinthectomy may be offered to patients with active disease who have failed less definitive therapy and have non-usable hearing 2
• Consider endolymphatic sac surgery as an extension of conservative treatment in select cases 4

Exclusion criteria: Patients with bilateral disease or contralateral hypofunction are not candidates for ablative procedures 1

Vestibular Rehabilitation

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy, not for acute vertigo management 2
• Benefits include improved symptom control and reduced fall risk 2

Treatments NOT Recommended

Positive Pressure Therapy

• Do not prescribe positive pressure therapy (Meniett device) based on systematic reviews and RCTs showing no significant difference compared to placebo 1, 2

Monitoring and Follow-Up

• Systematically document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment 2
• Obtain serial audiograms when assessing patients to track hearing fluctuations 2
• Adjust treatment based on symptom evolution and quality of life impact 2

Critical reality: There is no definitive cure for Ménière's disease, and evidence for many interventions remains limited 2. The natural history shows that if untreated for 10+ years, hearing may deteriorate as vertiginous episodes gradually subside 3.