What is the best treatment for Meniere's disease?

Best Treatment for Ménière's Disease

Start with dietary sodium restriction (1500-2300 mg daily) combined with lifestyle modifications, then add diuretics for maintenance therapy if attacks persist, reserving intratympanic gentamicin or steroids for refractory cases that fail conservative management. 1, 2

Stepwise Treatment Algorithm

First-Line: Dietary and Lifestyle Modifications

• Sodium restriction to 1500-2300 mg daily is the cornerstone of initial therapy to reduce endolymphatic fluid accumulation in the inner ear 1, 3, 2
• Limit caffeine intake, as it can trigger attacks in susceptible patients 3, 2
• Restrict alcohol consumption, which may precipitate vertigo episodes 3
• Identify and manage allergies, as they contribute to symptoms in up to 30% of patients 3, 2
• Implement stress reduction through relaxation techniques, regular exercise, and adequate sleep 3, 2
• Maintain a symptom diary to identify personal triggers 3

Acute Attack Management (20 minutes to 12 hours duration)

• Offer vestibular suppressants only during acute attacks—never for maintenance therapy 1, 2
• Use antihistamines (dimenhidrinato or meclizina) for acute vertigo control 3, 2
• Consider benzodiazepines cautiously for associated anxiety, but avoid prolonged use due to dependence risk and impaired vestibular compensation 3, 2

Second-Line: Maintenance Pharmacotherapy

• Add diuretics to modify electrolyte balance in the endolymph and reduce its volume when dietary measures alone are insufficient 1, 3, 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 3, 2

Important caveat: The American Academy of Otolaryngology-Head and Neck Surgery cannot make a definitive recommendation for betahistine due to questionable efficacy based on recent evidence 3. Diuretics remain the preferred pharmacologic maintenance option with moderate evidence quality 3, 2.

Third-Line: Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail after several months:

• Intratympanic steroids should be offered first for patients with active disease unresponsive to conservative therapy, providing 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy alone 3, 2

  • Benefits include better vertigo control, improved quality of life, and faster return to work 3, 2
  • Risks include hearing loss, tympanic membrane perforation, and persistent imbalance 3

• Intratympanic gentamicin is reserved for persistent vertigo after failed conservative therapies, achieving complete vertigo control in approximately 73.6% of patients 3, 2

  • This is an ablative approach that reduces vestibular function in the treated ear 4
  • Hearing status must be considered—gentamicin is more appropriate when hearing preservation is less critical 1

Vestibular Rehabilitation

• Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy 3, 2
• This promotes central vestibular compensation and improves balance, gait, and gaze stability 2
• Do not use for acute attack management 3

Surgical Options (Last Resort)

Reserved for cases failing all medical management:

• Endolymphatic sac surgery for hearing-preserving procedures 1, 2
• Labyrinthectomy for patients with non-usable hearing who have failed less definitive therapy 3
• Vestibular nerve section for severe refractory cases 1

Treatments NOT Recommended

Do not prescribe positive pressure therapy (Meniett device), as systematic reviews and RCTs show no significant difference compared to placebo 3, 2

Critical Monitoring Requirements

• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention 3, 2
• Obtain serial audiograms when assessing patients to track fluctuating low- to mid-frequency sensorineural hearing loss 1, 2
• Adjust treatment based on symptom evolution and quality of life impact 3

Common Pitfalls to Avoid

• Do not use vestibular suppressants for maintenance therapy—they impair central vestibular compensation and should only be used during acute attacks 2
• Avoid prolonged benzodiazepine use due to dependence risk 3
• Consider comorbidities (renal disease, cardiac disease, asthma) that may contraindicate certain medications 3
• Remember that up to 60% of placebo groups in RCTs show vertigo control, making treatment efficacy assessment challenging 1
• Recognize that there is no definitive cure for Ménière's disease—treatment goals focus on symptom control and quality of life improvement 1, 3