What are the management options for Meniere's disease?

Management of Menière's Disease

Clinicians should initiate treatment with patient education, dietary modifications (sodium restriction to 1500-2300 mg daily, limiting caffeine and alcohol), and offer diuretics or betahistine for maintenance therapy, while reserving vestibular suppressants strictly for acute vertigo attacks only. 1, 2

Initial Conservative Management

Patient Education (Essential First Step)

• Educate all patients about the natural history, symptom triggers, treatment options, and expected outcomes at diagnosis. 1
• Provide information across multiple visits with a patient advocate present to facilitate shared decision-making and improve adherence. 1
• Explain that while there is no definitive cure, symptoms can be controlled and often improve spontaneously over 2 years in many patients. 2, 3

Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily (American Heart Association ideal limit) to reduce endolymphatic fluid accumulation. 1, 2
• Limit caffeine consumption, as it triggers attacks in susceptible patients. 1, 2
• Limit alcohol intake, which can precipitate vertigo episodes. 1, 2
• Avoid nicotine exposure. 1
• Maintain adequate hydration with water while avoiding high-sugar beverages. 1
• Have patients keep a food and activity diary to identify individual triggers, as these vary considerably between patients. 1, 2

Important caveat: The evidence for dietary modifications is limited (Grade C), based primarily on observational studies rather than robust RCTs, but the low risk and potential benefit justify their use as first-line therapy. 1

Stress Management and Comorbidity Treatment

• Implement stress reduction through adequate sleep, regular exercise, meditation, and support groups, as stress exacerbates symptoms. 1
• Screen for and treat sleep apnea in patients with increased vertigo frequency. 1
• Identify and manage allergies, which may contribute to symptoms in up to 30% of patients. 1, 2

Pharmacotherapy for Acute Vertigo Attacks

Vestibular Suppressants (Limited Use Only)

• Offer a limited course of vestibular suppressants exclusively during acute attacks lasting 20 minutes to 12 hours—not for continuous use. 1, 2
• Antihistamines (meclizine, dimenhydrinate) are first-line options for acute symptom relief. 2
• Benzodiazepines may be used for associated anxiety but carry significant risk of dependence and should be prescribed with extreme caution. 1, 2

Critical warning: Vestibular suppressants impair vestibular compensation if used chronically and should never be prescribed for maintenance therapy. 1

Maintenance Pharmacotherapy

Diuretics and Betahistine

• Offer diuretics to modify endolymphatic electrolyte balance and reduce fluid volume for long-term symptom control. 1, 2
• Betahistine (a histamine analogue that increases inner ear vasodilation) may be offered, though recent evidence from the BEMED trial showed no significant difference versus placebo. 2
• The guideline cannot make a definitive recommendation for betahistine due to questionable efficacy based on this recent high-quality evidence. 2

Evidence quality note: Maintenance pharmacotherapy recommendations are based on Grade C evidence (observational studies), with limited RCT support. 1

Intratympanic Therapies (Second-Line)

When to Escalate

• Consider intratympanic therapies only for patients with active disease who fail conservative management with dietary modifications and oral medications. 2

Intratympanic Steroids

• Offer intratympanic steroids to patients not responding to non-invasive treatment, with 85-90% showing vertigo improvement versus 57-80% with conventional therapy. 2
• Benefits include better vertigo control, improved quality of life, and faster return to work. 2
• Risks include hearing loss, tympanic membrane perforation, and persistent imbalance. 2

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo despite failed conservative therapies, achieving complete vertigo control in approximately 73.6% of cases. 2
• Carries variable risk of hearing loss depending on administration protocol. 2

Surgical Options (Third-Line)

Indications for Surgery

• Consider surgical intervention only for severe, refractory cases that have failed all medical management. 1, 2
• Options include endolymphatic sac decompression (hearing-preserving) or labyrinthectomy (for non-usable hearing). 2

Treatments NOT Recommended

Positive Pressure Therapy

• Do not prescribe positive pressure therapy (Meniett device), as systematic reviews demonstrate no significant benefit over placebo. 1, 2

Vestibular Rehabilitation Timing

• Do not use vestibular rehabilitation for acute vertigo attacks. 2
• Reserve vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy to reduce fall risk. 2

Monitoring and Follow-Up

Documentation Requirements

• Systematically document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention. 2
• Obtain serial audiograms to track low-to-mid frequency sensorineural hearing loss progression. 2
• Regularly evaluate impact on quality of life and adjust treatment accordingly. 2

Common Pitfalls to Avoid

• Never use vestibular suppressants for chronic maintenance—they impair compensation and worsen long-term outcomes. 1
• Avoid prolonged benzodiazepine use due to addiction risk. 1
• Do not skip patient education—informed patients have better symptom control and adherence. 1
• Screen for contraindications before prescribing diuretics (renal/cardiac disease) or betahistine (asthma). 1
• Remember that many patients improve spontaneously over time, so avoid premature escalation to invasive therapies. 3