What are the treatment options for Meniere's disease?

Treatment Options for Meniere's Disease

Begin with dietary sodium restriction (1500-2300 mg daily) and lifestyle modifications, progress to diuretics or betahistine for maintenance therapy, then intratympanic steroids for refractory cases, reserving intratympanic gentamicin and surgery only when all else fails. 1

Stepwise Treatment Algorithm

First-Line: Dietary and Lifestyle Modifications

Sodium restriction to 1500-2300 mg daily is the cornerstone of initial management to reduce endolymphatic fluid accumulation, though evidence quality is limited (Grade C). 1 This represents the least invasive approach with minimal risk.

Additional dietary modifications include:

• Caffeine restriction may benefit some patients based on observational data showing advantage to limiting intake 1
• Alcohol limitation is recommended as it can trigger attacks in susceptible individuals 2
• Allergy management should be addressed, as allergies may contribute to symptoms in up to 30% of patients 1

Stress reduction through relaxation techniques and cognitive-behavioral strategies showed benefit in one RCT, making this a valuable adjunct to dietary changes. 1

Important caveat: A 2023 Cochrane review found very low certainty evidence for dietary interventions, with no placebo-controlled RCTs for commonly recommended interventions like salt or caffeine restriction. 3 Despite this limitation, these modifications remain first-line recommendations due to their safety profile and clinical consensus. 4, 1

Acute Attack Management (20 minutes to 12 hours)

Offer a limited course of vestibular suppressants only during acute attacks, not for maintenance therapy as they impair central vestibular compensation. 1

Specific agents include:

• Antihistamines (dimenhydrinate, meclizine) for acute vertigo control 1, 2
• Benzodiazepines may be used cautiously for associated anxiety, but carry significant risk of dependence and impaired vestibular compensation 1, 2

Second-Line: Maintenance Pharmacotherapy

Diuretics and/or betahistine may be offered for maintenance therapy to reduce symptoms or prevent attacks (Grade C evidence). 1

• Diuretics modify electrolyte balance in endolymph and reduce its volume, with potential benefit based on observational studies and Cochrane review 1, 2
• Betahistine is a histamine analogue that increases inner ear vasodilation 1, 2, though the 2020 guideline notes questionable efficacy based on the BEMED trial, which found no significant difference between betahistine and placebo 2

Third-Line: Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail, offer or refer for intratympanic steroids first (Grade B evidence), as they provide 85-90% improvement in vertigo symptoms compared to 57-80% with conventional therapy. 1, 2 Benefits include improved vertigo control, quality of life, and avoidance of hearing loss risk, though risks include hearing loss (paradoxically), tympanic membrane perforation, and persistent imbalance. 1, 2

Intratympanic gentamicin is reserved for patients with persistent vertigo who have failed conservative therapies, achieving approximately 73.6% complete vertigo control across studies. 1, 2 This is an ablative therapy that reduces vestibular function in the treated ear, though complete ablation is not typically required for vertigo control. 5

Fourth-Line: Surgical Options

Surgery is reserved exclusively for cases failing all medical management, with choice depending on hearing status. 1, 2

• Endolymphatic sac surgery is an option when hearing is worth preserving, though the Danish Sham Surgery Study showed both active surgery and placebo resulted in approximately 70% vertigo reduction 1
• Labyrinthectomy may be offered to patients with active disease who have failed less definitive therapy and have non-usable hearing 2

Essential Adjunctive Therapy

Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy (Grade A evidence). 1, 2 This promotes central vestibular compensation and improves balance, gait, and gaze stability, with benefits including improved symptom control, safety, and quality of life. 1

Critical distinction: Do not use vestibular rehabilitation for acute vertigo attacks, only for chronic imbalance between episodes. 2

Treatment NOT Recommended

Do not prescribe positive pressure therapy (Meniett device), as systematic reviews and RCTs show no significant difference compared to placebo (Grade B evidence against). 1, 2

Monitoring Requirements

Systematically document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after treatment, and obtain serial audiograms when assessing patients. 1, 2 This allows for treatment adjustment based on symptom evolution and ensures early detection of hearing deterioration.

Maintain a symptom diary to identify personal triggers and patterns, which can guide individualized modifications. 2

Common Pitfalls to Avoid

• Do not use vestibular suppressants for maintenance therapy - they impair central compensation and should only be used during acute attacks 1
• Do not proceed to invasive therapies without adequate trial of conservative management - the stepwise approach must be followed 1
• Do not overlook comorbidities that may contraindicate certain medications (renal or cardiac disease with diuretics, asthma with certain antihistamines) 2
• Do not promise cure - no definitive cure exists for Meniere's disease, and patient education about realistic expectations is essential 2