What are the treatment options for Meniere disease?

Treatment Options for Ménière's Disease

Start with patient education, dietary modifications (sodium restriction 1500-2300 mg/day), and lifestyle changes as first-line therapy, then escalate to diuretics or betahistine for maintenance, reserving intratympanic therapies and surgery for refractory cases. 1, 2

Initial Management: Education and Conservative Measures

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

• 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, 3
• Restrict alcohol intake, which can precipitate vertigo episodes. 2, 3
• Identify and manage allergies, as they contribute to symptoms in up to 30% of patients. 1, 2
• Implement stress management through relaxation techniques, regular exercise, and adequate sleep. 2

Important caveat: A 2023 Cochrane review found very low certainty evidence for dietary modifications, with no placebo-controlled RCTs for commonly recommended interventions like salt or caffeine restriction. 4 However, these remain first-line recommendations due to low risk and potential individual benefit. 1, 2

Acute Attack Management

Vestibular Suppressants (During Attacks Only)

• Offer a limited course of vestibular suppressants exclusively during acute vertigo attacks—not for continuous use. 1, 2
• Use antihistamines (dimenhidrinato, meclizina) as first-line agents for acute vertigo. 2, 5
• Consider benzodiazepines cautiously for associated anxiety, recognizing risks of sedation, dependence, and impaired vestibular compensation. 1, 2

Critical pitfall: Prolonged use of vestibular suppressants impairs central vestibular compensation and should be avoided. 1

Maintenance Pharmacotherapy

Diuretics and Betahistine

• Offer diuretics to modify electrolyte balance in the endolymph and reduce its volume for maintenance therapy. 1, 2
• Betahistine (a histamine analogue) may be offered to increase inner ear vasodilation, though recent evidence questions its efficacy—the BEMED trial showed no significant difference versus placebo. 2, 6
• Contraindications include renal or cardiac disease for diuretics, and asthma for certain medications. 1

Evidence quality note: Maintenance pharmacotherapy recommendations are based on Grade C evidence (observational studies), reflecting the limited high-quality trial data available. 1

Intratympanic Therapies (For Refractory Disease)

Intratympanic Steroids

• Offer intratympanic steroids to patients with active Ménière's disease who fail non-invasive treatments, with 85-90% showing vertigo improvement versus 57-80% with conventional therapy. 2, 7
• Benefits include better vertigo control, improved quality of life, and faster return to work. 2
• Risks include hearing loss (the most concerning), tympanic membrane perforation, and persistent imbalance. 2, 7

Intratympanic Gentamicin

• Reserve gentamicin for patients with persistent vertigo despite conservative therapies, achieving complete vertigo control in approximately 73.6% of cases. 2
• Recognize that gentamicin carries significant hearing loss risk, making it appropriate only when hearing preservation is less critical. 2

Surgical Options (For Refractory Cases)

Hearing-Preserving Procedures

• Consider endolymphatic sac decompression or vestibular nerve section for patients failing medical management who have usable hearing. 7, 8

Ablative Procedures

• Labyrinthectomy may be offered to patients with non-usable hearing who have failed less definitive therapies, though it sacrifices remaining hearing. 2, 7
• Cochlear implantation can restore substantial hearing function even after ablative procedures. 7

Therapies NOT Recommended

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

Monitoring and Follow-Up

• Obtain regular audiograms to document hearing progression or stabilization. 2, 7
• Systematically document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention. 2
• Assess quality of life impact as part of ongoing management. 1, 7

Critical Clinical Pearls

• No cure exists for Ménière's disease—all treatments are symptomatic and preventive. 2, 8
• Hearing loss often progresses despite treatment, initially fluctuating in low-to-mid frequencies before involving all frequencies. 7, 6
• Bilateral involvement occurs in 25-40% of cases over time. 6
• The stepwise approach (conservative → pharmacologic → intratympanic → surgical) minimizes risks while maximizing potential benefit. 2