What are the treatment options for Meniere's disease?

Treatment of Menière's Disease

Start with dietary sodium restriction to 1500-2300 mg daily and lifestyle modifications, then escalate to diuretics or betahistine for maintenance therapy, followed by intratympanic therapies for refractory cases, and reserve surgery only when all else fails. 1

Stepwise Treatment Algorithm

First-Line: Dietary and Lifestyle Modifications

Implement these interventions immediately upon diagnosis, though evidence quality is limited (Grade C). 1

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear 1, 2
• Limit caffeine consumption based on observational data showing benefit in some patients 1, 2
• Restrict alcohol intake as it can trigger attacks in susceptible individuals 2
• Address allergies aggressively since they may contribute to symptoms in up to 30% of patients based on observational studies 1, 2
• Implement stress reduction through relaxation techniques and cognitive-behavioral strategies, which showed benefit in one RCT 1, 2
• Maintain a symptom diary to identify personal triggers and patterns 2

Important caveat: While these modifications are universally recommended as first-line therapy, 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 interventions carry minimal harm and align with consensus guidelines. 1

Acute Attack Management (20 Minutes to 12 Hours)

Use vestibular suppressants only during acute attacks—never for maintenance therapy as they impair central vestibular compensation. 1

• Prescribe antihistamines (dimenhydrinate or meclizine) for acute vertigo control 1, 2
• Consider benzodiazepines cautiously for associated anxiety, but warn patients about dependence risk and impaired vestibular compensation 1, 2
• Do not continue suppressants between attacks as they prevent the brain from adapting to vestibular dysfunction 1

Maintenance Pharmacotherapy (Grade C Evidence)

Offer diuretics and/or betahistine to reduce attack frequency, recognizing the evidence is observational rather than from high-quality RCTs. 1

• Diuretics modify electrolyte balance in the endolymph and reduce its volume, with potential benefit based on Cochrane review and observational studies 1, 2
• Betahistine (histamine analogue) increases inner ear vasodilation, though the recent BEMED trial showed no significant difference versus placebo, making the evidence questionable 2, 4

Critical consideration: The American Academy of Otolaryngology-Head and Neck Surgery cannot make a definitive recommendation for betahistine due to conflicting evidence, with the most recent high-quality trial (BEMED) showing no benefit over placebo. 2 Diuretics remain the preferred maintenance option when pharmacotherapy is needed. 1, 2

Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail after adequate trial (typically 3-6 months), escalate to intratympanic therapies. 1

Intratympanic Steroids (Grade B Evidence)

• Offer to patients with active disease unresponsive to conservative measures 1, 2
• Benefits include: 85-90% improvement in vertigo symptoms (versus 57-80% with conventional therapy), improved quality of life, faster return to work, and avoidance of hearing loss risk 1, 2
• Risks include: hearing loss, tympanic membrane perforation, and persistent imbalance 2

Intratympanic Gentamicin

• Reserve for patients with persistent vertigo who have failed all conservative therapies 1, 2
• Achieves complete vertigo control in approximately 73.6% of patients across studies 1, 2
• Carries risk of hearing loss that varies by administration method—use cautiously and counsel patients thoroughly 2

Vestibular Rehabilitation (Grade A Evidence—Strongest Recommendation)

Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy. 1

• Promotes central vestibular compensation and improves balance, gait, and gaze stability 1, 2
• Benefits include: improved symptom control, reduced fall risk, enhanced safety, and better quality of life 1, 2
• Do not use for acute attacks—only for chronic imbalance management 2

Surgical Options (Last Resort Only)

Reserve surgery for cases failing all medical management, with choice depending on hearing status. 1

Hearing-Preserving Procedures

• Endolymphatic sac surgery when hearing is worth preserving, though the Danish Sham Surgery Study showed both active surgery and placebo resulted in ~70% vertigo reduction, questioning efficacy 1
• Vestibular nerve section for vertigo control while preserving hearing 5

Ablative Procedures

• Labyrinthectomy for patients with non-usable hearing and persistent vertigo despite all other treatments 1, 5
• Critical warning: Inform patients that Menière's disease affects the contralateral ear in some cases, which could leave them without meaningful hearing or vestibular function bilaterally if ablative surgery is performed 6

Hearing Rehabilitation Options

Address progressive hearing loss with appropriate amplification strategies. 5

• Conventional hearing aids for patients with usable hearing 5
• CROS hearing aids when speech discrimination is severely compromised 5
• Bone-anchored devices for severe to profound hearing loss in the affected ear with normal hearing in the better ear 5
• Cochlear implants for severe bilateral hearing loss where amplification provides limited benefit, even after ablative procedures like labyrinthectomy 5

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

Essential Monitoring Requirements

Document outcomes systematically to guide treatment adjustments. 1, 2

• Track resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment intervention 1, 2
• Obtain serial audiograms when assessing patients to monitor hearing progression 1, 5
• Assess quality of life impact as part of ongoing management 5
• Distinguish between temporary fluctuations in hearing and permanent progression, as this guides treatment decisions 5

Patient Education Priorities

Educate patients about the chronic nature of the disease and realistic treatment expectations. 6, 1

• Explain that no definitive cure exists—treatment focuses on symptom control and preventing progression 2
• Discuss natural history: fluctuating symptoms initially, with potential for progressive hearing loss over time despite treatment 5
• Provide information both verbally and in written handouts at a comprehension level appropriate for the patient 6
• Allow sufficient time for questions to promote shared decision-making, as time constraints are a major barrier to effective patient education 6
• Warn about bilateral involvement occurring in 25-40% of cases before considering ablative procedures 4