What are the treatment options for Meniere's disease?

Treatment Options for Ménière's Disease

Start with patient education, dietary modifications (sodium restriction 1500-2300 mg/day, caffeine and alcohol limitation), and diuretics or betahistine for maintenance therapy, reserving vestibular suppressants only for acute vertigo attacks, and escalating to intratympanic steroids or gentamicin only when non-invasive treatments fail. 1, 2

Initial Management: Education and Lifestyle Modifications

Patient education is mandatory and should cover the natural history of the disease, symptom control measures, treatment options, and expected outcomes to enable shared decision-making and improve quality of life. 1

Dietary and Lifestyle Interventions

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear. 2 While a 2023 Cochrane review found very low certainty evidence for dietary modifications 3, the American Academy of Otolaryngology-Head and Neck Surgery maintains this recommendation based on observational data and clinical experience. 1

• Limit caffeine consumption as it may trigger attacks in susceptible patients, though evidence quality is limited. 1, 2

• Restrict alcohol intake since it can precipitate vertigo episodes. 2, 4

• 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. 1, 2

• Maintain a symptom diary to identify personal triggers and patterns. 2

Critical caveat: Despite widespread use, the evidence for dietary modifications remains weak (Grade C), with only one small negative RCT on sodium restriction. 1 However, individual patients may benefit from identifying specific triggers. 1

Acute Attack Management

Offer vestibular suppressants only during acute vertigo attacks lasting 20 minutes to 12 hours—never for chronic maintenance. 1, 2

• Antihistamines (dimenhidrinato, meclizine) are first-line for acute vertigo control. 2

• Benzodiazepines can be used cautiously for associated anxiety, but carry dependence risk with prolonged use. 1, 2

Important warning: Vestibular suppressants should be limited in duration to avoid impairing vestibular compensation and creating dependency. 1

Maintenance Pharmacotherapy

Offer diuretics and/or betahistine as maintenance therapy to reduce attack frequency and severity. 1, 2

• Diuretics modify electrolyte balance in the endolymph and reduce its volume, though evidence is based primarily on observational studies (Grade C). 1, 2

• Betahistine (a histamine analogue) increases inner ear vasodilation, but recent evidence including the BEMED trial showed no significant difference versus placebo in reducing vertigo attacks. 2 Despite this, it remains an option based on earlier observational data. 1

Contraindications to consider: Exclude patients with renal or cardiac disease (for diuretics), asthma, or medication allergies. 1

Intratympanic Therapies for Refractory Disease

Offer intratympanic steroids to patients with active Ménière's disease not responding to non-invasive treatment. 1, 2

• Intratympanic steroids achieve 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy, with faster return to work and improved quality of life. 1, 2

• Risks include: Hearing loss, tympanic membrane perforation, persistent imbalance, and need for multiple treatments. 1

For patients failing intratympanic steroids:

• Intratympanic gentamicin achieves complete vertigo control in approximately 73.6% of patients, but carries variable hearing loss risk depending on administration protocol. 2

• This is appropriate for patients who have failed less invasive therapies and are willing to accept potential hearing compromise. 2

Surgical Options for Severe Refractory Cases

Reserve surgical interventions for patients failing all medical and intratympanic therapies. 1

• Labyrinthectomy may be offered to patients with non-usable hearing who have failed less definitive therapy. 2

• Endolymphatic sac decompression is considered for hearing preservation in select cases. 5

Surgical decisions require specialist consultation given the complexity and irreversibility of ablative procedures. 1

Treatments NOT Recommended

Do not prescribe positive pressure therapy (Meniett device) as systematic reviews and randomized trials demonstrate no effectiveness compared to placebo. 1, 2

Do not use vestibular rehabilitation for acute vertigo attacks, though it may benefit chronic imbalance between attacks or following ablative therapy. 2

Monitoring and Follow-Up

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

• Obtain serial audiograms to track hearing fluctuation and progression. 2

• Assess quality of life impact regularly and adjust treatment based on symptom evolution. 2

• Recognize that there is no definitive cure for Ménière's disease—treatment goals focus on symptom control and preventing progression. 2

Critical Clinical Pitfalls

• Avoid prolonged vestibular suppressant use as it impairs central compensation and creates dependency. 1

• Monitor for hyponatremia with aggressive sodium restriction, though this has not been reported in studies when appropriate nutritional counseling is provided. 1

• Consider bilateral disease before proceeding with ablative therapies, as this would eliminate vestibular function entirely. 1

• Exclude patients with contralateral disease or hypofunction from intratympanic gentamicin therapy. 1