What are the treatment options for Ménière’s disease?

Treatment Options for Ménière's Disease

Begin with dietary modifications (sodium restriction to 1500-2300 mg/day, limiting caffeine and alcohol) and patient education, then escalate to diuretics or betahistine for maintenance therapy, followed by intratympanic steroids for refractory cases, reserving ablative procedures only for severe, treatment-resistant 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 enable shared decision-making and improve quality of life. 1
• Encourage patients to maintain a symptom diary to identify personal triggers for attacks. 2
• Explain that while symptoms can be managed, no definitive cure exists and hearing loss often progresses despite treatment. 2, 3

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation, though evidence quality is limited (Grade C). 1, 2
• Limit caffeine consumption as it may trigger attacks in susceptible patients. 2
• Restrict alcohol intake, which can precipitate vertigo episodes. 2, 4
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep. 2
• Identify and treat allergies, as they contribute to symptoms in up to 30% of patients. 1, 2

Important caveat: Despite widespread recommendation, a 2023 Cochrane review found no randomized controlled trials supporting salt, caffeine, or alcohol restriction, making the evidence very uncertain. 5, 6 However, given the low risk of harm and potential benefit in individual patients, these modifications remain reasonable first-line interventions. 1

Pharmacotherapy for Acute Vertigo Attacks

Vestibular Suppressants (Use Sparingly)

• Offer a limited course of vestibular suppressants only during acute vertigo attacks, not for chronic use. 1, 2
• Antihistamines (dimenhidrinato, meclizina) are first-line options for acute symptom relief. 2
• Benzodiazepines may be used cautiously for associated anxiety, but avoid prolonged use due to dependence risk and impaired vestibular compensation. 1, 2

Critical pitfall: Do not prescribe vestibular suppressants for maintenance therapy, as they impair vestibular compensation and worsen long-term balance outcomes. 1

Maintenance Pharmacotherapy

Diuretics and Betahistine

• Consider diuretics (thiazide-type) to modify endolymphatic electrolyte balance and reduce fluid volume for maintenance therapy. 1, 2
• Betahistine (histamine analogue) may increase inner ear vasodilation, though recent evidence questions its efficacy—the BEMED trial showed no significant difference versus placebo. 2
• Both options have Grade C evidence quality with a preponderance of benefit over harm. 1

Important consideration: Exclude patients with renal or cardiac disease before prescribing diuretics, and monitor for hyponatremia risk. 1, 2

Intratympanic Therapies (For Refractory Disease)

Intratympanic Steroids

• Offer intratympanic steroids to patients with active Ménière's disease not responsive to non-invasive treatment, with 85-90% showing vertigo improvement. 2, 3
• Benefits include improved vertigo control, quality of life, faster return to work, and avoidance of general anesthesia. 1
• Risks include hearing loss (10-15%), tympanic membrane perforation, and persistent imbalance requiring multiple treatments. 1, 2

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo after failed conservative therapies, achieving complete vertigo control in approximately 73.6% of cases. 2
• Contraindicated in patients with contralateral disease or hypersensitivity to aminoglycosides. 1
• Carries variable hearing loss risk depending on administration protocol. 2

Surgical Options (Last Resort)

Hearing-Preserving Procedures

• Endolymphatic sac decompression may stabilize hearing and control vertigo in select patients. 3, 7
• Vestibular nerve section controls vertigo while preserving hearing. 3

Ablative Procedures

• Labyrinthectomy is reserved for patients with non-usable hearing and failed less definitive therapies. 2, 3
• Cochlear implantation can restore hearing function even after ablative procedures. 3

Treatments NOT Recommended

• Do not prescribe positive pressure therapy (Meniett device)—systematic reviews show no significant benefit versus placebo. 1, 2
• Vestibular rehabilitation is not effective for acute vertigo attacks but may help chronic imbalance between episodes. 2

Monitoring and Follow-Up

• Obtain baseline and serial audiograms to document hearing progression. 2, 3, 8
• Systematically document changes in vertigo frequency/severity, tinnitus, hearing loss, and quality of life after each intervention. 2, 3
• Adjust treatment based on symptom evolution, recognizing that hearing often worsens despite optimal management. 3