From the Guidelines
Meniere's disease treatment should focus on managing symptoms and preventing vertigo attacks, with initial treatment including lifestyle modifications and medications, and more invasive options for severe cases unresponsive to medication, as recommended by the 2020 clinical practice guideline 1. The goals of treatment are to prevent or reduce vertigo severity and frequency, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve quality of life. Some key treatment options include:
- Lifestyle modifications, such as reducing salt intake to less than 2 grams daily, avoiding caffeine, alcohol, and tobacco, and managing stress.
- Medications, including diazepam (Valium) 2-5mg or lorazepam (Ativan) 0.5-1mg for vertigo, and antiemetics like ondansetron (Zofran) 4-8mg or promethazine (Phenergan) 12.5-25mg for nausea.
- Diuretics, such as hydrochlorothiazide 25-50mg daily or acetazolamide 250mg twice daily, to reduce inner ear fluid pressure.
- Betahistine (Serc) 16-24mg three times daily, which may improve blood flow to the inner ear and reduce symptoms, though it's not FDA-approved in the US. For severe cases, more invasive options include:
- Intratympanic steroid or gentamicin injections, which can reduce vertigo symptoms and are less invasive than surgical ablation.
- Endolymphatic sac decompression surgery, which can help relieve symptoms by reducing endolymphatic fluid pressure.
- Vestibular nerve section, which can help control vertigo symptoms by disrupting the vestibular nerve. These treatments work by reducing endolymphatic fluid pressure in the inner ear, which is believed to cause the characteristic symptoms of vertigo, hearing loss, tinnitus, and aural fullness in Meniere's disease, as supported by the evidence from the 2020 clinical practice guideline 1.
From the Research
Treatment Options for Meniere's Disease
- Conservative measures, including low salt diet, avoidance of stress and caffeine, and sleep hygiene, are often the first line of treatment 2
- Medical therapy with a diuretic, such as hydrochlorothiazide, is commonly used to treat Meniere's disease, with some studies suggesting its effectiveness in reducing vertigo and improving hearing outcomes 3, 4
- Betahistine, a histamine analog, has also been shown to be effective in reducing vertigo and improving hearing outcomes in some patients with Meniere's disease 3, 5
- Intratympanic (IT) steroids and IT gentamicin are also used to treat Meniere's disease, with IT gentamicin being associated with a higher probability of achieving complete vertigo control, but potentially detrimental to hearing preservation 5
- Surgical options, such as endolymphatic sac surgery, are also available, but their effectiveness is still a topic of debate 2, 5
Pharmacologic Therapies
- A systematic review and network meta-analysis found that IT steroid plus high-dose betahistine may be the best treatment option among pharmacologic interventions for achieving both hearing preservation and vertigo control 5
- Diuretics, such as hydrochlorothiazide, have been shown to be effective in reducing vertigo episode frequency, but their effectiveness in improving hearing outcomes is less convincing 4
- However, some studies have raised concerns about the potential harm of diuretics in Meniere's disease, suggesting that they may cause more harm than good due to their potential to induce local ischemia and damage to the inner ear 6
Surgical Therapies
- Endolymphatic sac surgery has been shown to be effective in reducing vertigo episode frequency, but its effectiveness in improving hearing outcomes is still a topic of debate 2, 5
- Vestibular nerve section or labyrinthectomy are rarely considered for patients with severe symptoms who do not show a reduction in vestibular function with gentamicin 2