What is the recommended dose and frequency of betahistine (Histamine receptor agonist) for treating Meniere's disease?

Betahistine Dosing for Meniere's Disease

The recommended dose of betahistine for Meniere's disease is 48 mg daily (either as 24 mg twice daily or 48 mg once daily), though the evidence for its efficacy is weak and conflicting. 1, 2

Standard Dosing Regimen

• Start with 48 mg daily, divided as 24 mg twice daily or as a single 48 mg modified-release formulation 1, 3
• Treatment duration should be at least 3 months to evaluate efficacy, with most guidelines suggesting reassessment at 6-9 months 1, 2
• If no improvement occurs after 6-9 months, continued betahistine therapy is unlikely to be beneficial and should be discontinued 1

Evidence Quality and Limitations

The recommendation for betahistine comes with significant caveats. The 2020 American Academy of Otolaryngology-Head and Neck Surgery guideline explicitly states they cannot make a definitive recommendation for betahistine use in controlling Meniere's disease symptoms due to conflicting evidence 2. This is primarily based on the high-quality BEMED trial, which found:

• No significant difference between betahistine (either 48 mg/day or 144 mg/day) and placebo in reducing vertigo attacks over 9 months 4
• Attack rate ratios compared to placebo were 1.036 for low-dose (48 mg) and 1.012 for high-dose (144 mg), meaning essentially no benefit 4
• Higher doses (144 mg/day) showed no advantage over standard doses 1

Dosing Variations Studied

While 48 mg daily is standard, some studies have examined higher doses:

• Low-dose regimen: 48 mg/day (24 mg twice daily) 4
• High-dose regimen: 144 mg/day (48 mg three times daily) - showed no additional benefit 4
• One retrospective study reported a mean effective dose of 87.5 ± 27.2 mg per day, but found no correlation between dose and symptom control 5

Contraindications and Safety Monitoring

• Absolute contraindication: pheochromocytoma 1, 2
• Use with caution in asthma and peptic ulcer disease 2
• Common side effects include headache, balance disorder, nausea, and upper gastrointestinal symptoms 1, 2
• No routine laboratory monitoring is required 6

Clinical Decision Algorithm

If prescribing betahistine despite limited evidence:

1. Start with 48 mg daily (24 mg twice daily or 48 mg once daily modified-release) 1, 3
2. Reassess at 3 months for any symptom improvement or stabilization 1
3. If no benefit by 6-9 months, discontinue therapy 1
4. Do not escalate to higher doses, as 144 mg/day showed no additional benefit over 48 mg/day 4

Important Clinical Caveat

The most recent high-quality evidence (BEMED trial, 2016) found betahistine no better than placebo, yet it remains widely prescribed 4. The American Academy of Otolaryngology-Head and Neck Surgery's inability to recommend betahistine reflects this evidence gap 2. If vertigo control is the priority, consider alternative treatments such as intratympanic gentamicin for refractory cases, which showed significant reduction in vertigo attacks (from 74 attacks/year to zero) in controlled studies 7.