What are the treatment options for Ménière’s disease?

Treatment of Ménière's Disease

The American Academy of Otolaryngology-Head and Neck Surgery recommends a stepwise treatment approach starting with dietary modifications and patient education, progressing to diuretics or betahistine for maintenance, then intratympanic therapies for refractory cases, and finally surgical options only when all else fails. 1

Initial Management: Lifestyle and Dietary Modifications

Clinicians should counsel patients on dietary and lifestyle modifications as first-line therapy, despite limited evidence quality (Grade C). 1

• Sodium restriction to 1500-2300 mg daily is recommended to reduce endolymphatic fluid accumulation, though one small RCT showed negative results with study limitations 1, 2
• Caffeine restriction may benefit some patients based on observational data showing advantage to limiting intake 1, 2
• Alcohol limitation is advised as it can trigger attacks in susceptible individuals 2, 3
• Allergy management should be addressed, as allergies may contribute to symptoms in up to 30% of patients based on observational studies and animal literature 1, 2
• Stress reduction through relaxation techniques and cognitive-behavioral strategies showed benefit in one RCT 1, 2
• Symptom diaries help identify individual triggers and empower patients in their care 2

Important caveat: The evidence for dietary modifications is weak, with a Cochrane review finding very low certainty evidence and no placebo-controlled RCTs for commonly recommended interventions like salt or caffeine restriction 4. However, individual patients may have identifiable triggers that improve symptom control 1.

Acute Attack Management

Clinicians should offer a limited course of vestibular suppressants only during acute Ménière's disease attacks lasting 20 minutes to 12 hours. 1, 2

• Antihistamines (dimenhidrinato, meclizina) are recommended for acute vertigo control 2
• Benzodiazepines may be used cautiously for associated anxiety, but carry risk of dependence and impaired vestibular compensation 1, 2
• Do not use vestibular suppressants for maintenance therapy as they impair central compensation 1

Maintenance Pharmacotherapy

Clinicians may offer diuretics and/or betahistine for maintenance therapy to reduce symptoms or prevent attacks (Grade C evidence, Option statement). 1

Diuretics

• Modify electrolyte balance in endolymph and reduce its volume 2, 5
• Based on observational studies and Cochrane review showing potential benefit 1, 2
• Contraindicated in patients with renal or cardiac disease 1
• Monitor for hyponatremia risk, though not reported in studies 1

Betahistine

• A histamine analogue that increases inner ear vasodilation 2, 5
• Evidence is mixed: the recent BEMED trial found no significant difference versus placebo in reducing vertigo attacks 2
• International consensus still recommends it as first-line conservative treatment 5
• Not available in all countries (e.g., United States)

Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail, clinicians should offer or refer for intratympanic therapies (Grade B evidence for steroids). 1

Intratympanic Steroids

• Offer to patients with active disease not responsive to non-invasive treatment 1, 2
• Show 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy 2
• Benefits include improved vertigo control, quality of life, faster return to work, and avoidance of hearing loss risk compared to ablative procedures 1
• Risks include hearing loss, tympanic membrane perforation, persistent imbalance, and need for multiple treatments 1

Intratympanic Gentamicin

• Reserved for patients with persistent vertigo who have failed conservative therapies 2, 6
• Achieves complete vertigo control in approximately 73.6% of cases 2
• Works by reducing vestibular function in the treated ear, though complete ablation is not typically required 6
• Carries variable risk of hearing loss depending on administration method (low-dose protocols preferred) 2, 6
• Contraindicated in patients with contralateral disease or hypersensitivity to aminoglycosides 1

Vestibular Rehabilitation

Clinicians should offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy (Grade A evidence, Recommendation). 1, 2

• Promotes central vestibular compensation and improves balance, gait, and gaze stability 1
• Benefits include improved symptom control, safety, reduced fall risk, improved confidence and quality of life 1
• Do not use during acute attacks - it is ineffective acutely and may exacerbate symptoms 1
• Particularly important for bilateral Ménière's disease patients who have limited ability to compensate and higher fall risk 1

Surgical Options for Refractory Cases

Surgery is reserved for cases failing all medical management, with choice depending on hearing status. 2, 5

When Hearing is Worth Preserving

• Endolymphatic sac surgery is an option, though the Danish Sham Surgery Study showed both active surgery and placebo (mastoidectomy alone) resulted in ~70% vertigo reduction 1
• Vestibular nerve section is the most definitive option when hearing preservation is desired 5, 7

When Hearing is Non-Serviceable

• Labyrinthectomy may be offered to patients with non-usable hearing who have failed less definitive therapy 2, 7
• May be combined with cochlear implantation 5

Treatments NOT Recommended

Clinicians should not prescribe positive pressure therapy (Meniett device) to patients with Ménière's disease. 1, 2

• Systematic reviews and RCTs show no significant difference compared to placebo 1, 2
• This is a Recommendation Against based on Grade B evidence 1

Patient Education and Monitoring

Clinicians should educate patients about natural history, symptom control measures, treatment options, and outcomes (Grade C evidence, Recommendation). 1

• One RCT showed benefit of patient education booklet for symptom control through self-management 1
• Enables shared decision-making and patient empowerment 1

Systematic documentation is essential: 2

• Track resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment 2
• Obtain serial audiograms when assessing patients 2
• Adjust treatment based on symptom evolution 2

Critical Clinical Pearls

• No cure exists for Ménière's disease - treatment goals are symptom control and quality of life improvement 2
• The natural history involves progressive unilateral peripheral vestibular decline with central compensation 1
• Bilateral disease carries significantly higher fall risk and worse outcomes 1
• Evidence quality is limited for many interventions, particularly dietary modifications 1, 4
• The remarkable placebo response (~70%) in the Danish study highlights the complexity of this disease and need for rigorous research 1