Does Meniere's disease cause nystagmus?

Does Ménière's Disease Cause Nystagmus?

Yes, Ménière's disease definitively causes nystagmus during acute vertigo attacks, with spontaneous nystagmus being a hallmark feature that occurs in 100% of patients during vertiginous episodes. 1

Nystagmus Characteristics During Acute Attacks

Direction and Pattern

• Horizontal nystagmus is the predominant type, occurring in approximately 94% of patients during acute Ménière's attacks 1
• Vertical nystagmus (either down-beating or up-beating) occurs in approximately 5-6% of cases 2, 1
• The nystagmus can be either irritative type (beating toward the affected ear) or deficit type (beating away from the affected ear) 2, 3

Direction Reversal - A Key Feature

• Direction reversal of nystagmus occurs in approximately 59% of patients, making this a characteristic finding in Ménière's disease 1
• This reversal can occur within the same episode (34% of patients) or across different attacks (24% of patients) 1
• The reversal pattern varies: some patients show ipsiversive-to-contraversive nystagmus (19%), while others demonstrate contraversive-to-ipsiversive reversal (13%) 1

Intensity Characteristics

• Ictal (during attack) nystagmus has a mean slow-phase velocity of 42.8°/s, which is significantly faster than interictal nystagmus (1.4°/s) 1
• The intensity of nystagmus correlates with the severity of the vertiginous attack 3
• Nystagmus can be continuous or intermittent depending on attack severity 3

Clinical Diagnostic Implications

Distinguishing from Other Vestibular Disorders

• Nystagmus findings help differentiate Ménière's disease from BPPV: BPPV causes positional nystagmus lasting seconds, while Ménière's causes spontaneous nystagmus lasting 20 minutes to 12 hours 4
• Using ictal nystagmus slow-phase velocity >12°/s combined with caloric canal paresis >25% can distinguish Ménière's disease from vestibular migraine with 95.7% sensitivity and 85.1% specificity 1

Red Flags for Central Causes

• Down-beating nystagmus on Dix-Hallpike maneuver suggests a central (neurological) cause rather than Ménière's disease 4, 5
• Direction-changing nystagmus without head position changes (periodic alternating nystagmus) indicates central pathology 4
• Baseline nystagmus without provocative maneuvers suggests central rather than peripheral vestibular dysfunction 4

Practical Clinical Considerations

Documentation During Attacks

• Patients can successfully self-record nystagmus using mobile phone video during attacks, providing objective documentation of vertigo episodes 2
• This video documentation is particularly valuable when considering ablative treatments like chemical labyrinthectomy 2
• Portable video oculography can capture nystagmus characteristics that aid in diagnosis 1

Important Caveats

• The direction of nystagmus does NOT reliably indicate which ear is affected in Ménière's disease, as direction can vary and reverse 2
• The affected side is determined by audiometric documentation of low-to-mid frequency sensorineural hearing loss, not by nystagmus direction 4
• Nystagmus may be absent between attacks, so examination during asymptomatic periods may not reveal this finding 6

Post-Treatment Nystagmus

• Following intratympanic gentamicin treatment, some patients develop "irritative" spontaneous nystagmus during early post-treatment period, which may represent a recovery phenomenon 7