What are the treatment options for Meniere's disease?

Treatment of Ménière's Disease

Stepwise Treatment Algorithm

Start with dietary modifications and patient education, progress to diuretics or betahistine for maintenance therapy, then intratympanic therapies for refractory cases, and reserve surgery only when all else fails. 1

First-Line: Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation, though evidence quality is limited (Grade C). 2, 1
• Limit caffeine consumption, as observational data shows benefit in some patients. 2, 1
• Restrict alcohol intake, which can trigger attacks in susceptible individuals. 1, 3
• Address allergies aggressively, as they may contribute to symptoms in up to 30% of patients based on observational studies and animal literature. 2, 1
• Implement stress reduction through relaxation techniques and cognitive-behavioral strategies, which showed benefit in one RCT. 2, 1
• Have patients maintain a symptom diary to identify personal triggers. 1

Common pitfall: Despite widespread recommendation, a 2023 Cochrane review found very low certainty evidence for dietary modifications, with no placebo-controlled RCTs for salt or caffeine restriction. 4 However, given the low risk and potential individual benefit, these remain first-line recommendations. 2

Acute Attack Management (20 Minutes to 12 Hours)

• Offer a limited course of vestibular suppressants ONLY during acute attacks—never for maintenance therapy as they impair central vestibular compensation. 2, 1
• Use antihistamines (dimenhydrinate, meclizine) as first-line agents for acute vertigo control. 1
• Consider benzodiazepines cautiously for associated anxiety, but warn patients about dependence risk and impaired vestibular compensation. 2, 1

Maintenance Pharmacotherapy

• Offer diuretics and/or betahistine to reduce symptoms or prevent attacks (Grade C evidence, Option statement). 2, 1
• Diuretics modify electrolyte balance in endolymph and reduce its volume, with support from observational studies and Cochrane review. 2, 1
• Betahistine increases inner ear vasodilation through histamine analogue action, though evidence is mixed and the BEMED trial showed no significant difference versus placebo. 1, 5

Important caveat: Exclude patients with renal or cardiac disease, asthma, or medication allergies before prescribing. 2 Monitor for hyponatremia with diuretics, though this has not been reported in studies. 2

Intratympanic Therapies for Refractory Disease

When non-invasive treatments fail after adequate trial:

• Offer intratympanic steroids first (Grade B evidence), which provide 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy. 1, 5

• Benefits include improved vertigo control, quality of life, faster return to work, and avoidance of hearing loss risk compared to gentamicin. 2, 1

• Risks include hearing loss (paradoxically), tympanic membrane perforation, and persistent imbalance. 1, 5

• Reserve intratympanic gentamicin for patients with persistent vertigo who have failed conservative therapies, achieving approximately 73.6% complete vertigo control. 1, 5

• Gentamicin reduces vestibular function in the treated ear without requiring complete ablation. 6

• Risk of hearing loss varies by administration method (low-dose protocols preferred). 1, 6

Vestibular Rehabilitation

• Offer vestibular rehabilitation/physical therapy for chronic imbalance between attacks or following ablative therapy (Grade A evidence, Recommendation). 1, 5
• Promotes central vestibular compensation and improves balance, gait, and gaze stability. 1
• Do NOT use for acute attack management. 1

Surgical Options (Last Resort)

Reserve for cases failing all medical management:

• 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. 1
• Vestibular nerve section for hearing-sparing vertigo control. 7
• Labyrinthectomy for patients with non-usable hearing who have failed less definitive therapy—sacrifices remaining hearing but controls vertigo. 5, 7

Treatments 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, Recommendation Against). 2, 1, 5

Essential Patient Education

• Educate patients about natural history, symptom control measures, treatment options, and outcomes to enable shared decision-making (Grade C evidence, Recommendation). 2, 1
• Emphasize that no cure exists—treatment is symptomatic and preventive. 5
• Warn that hearing loss often worsens over time despite treatment interventions. 7

Monitoring Requirements

• Document resolution, improvement, or worsening of vertigo, tinnitus, and hearing loss after each treatment. 1, 5
• Obtain serial audiograms when assessing patients to track hearing progression. 1, 7
• Assess quality of life impact as part of ongoing management. 2, 7

Critical distinction: Differentiate between temporary fluctuations in hearing and permanent progression, as this guides treatment decisions, particularly for surgical interventions. 7