What are the treatment options for a patient with Meniere's disease?

Treatment of Ménière's Disease

Start with dietary sodium restriction (1500-2300 mg daily) and lifestyle modifications, then add diuretics or betahistine for maintenance therapy, progress to intratympanic steroids for refractory cases, and reserve surgical options only when all medical management fails. 1

First-Line Treatment: Dietary and Lifestyle Modifications

• Restrict sodium intake to 1500-2300 mg daily to reduce endolymphatic fluid accumulation in the inner ear 2, 1
• Limit caffeine consumption, as it may trigger attacks in susceptible patients 2, 1
• Limit alcohol intake, which can precipitate vertigo episodes 2, 3
• Address allergies aggressively, as they contribute to symptoms in up to 30% of patients 2, 1
• Implement stress reduction techniques including relaxation exercises, regular physical activity, and adequate sleep 2, 1
• Maintain a symptom diary to identify personal triggers and patterns 2

These modifications should be attempted first despite limited evidence quality, as they carry minimal risk and may provide substantial benefit 1

Acute Attack Management (During 20-Minute to 12-Hour Episodes)

• Use vestibular suppressants only during acute attacks, not for maintenance therapy, as they impair central vestibular compensation 1
• Prescribe antihistamines (dimenhidrinato or meclizina) for acute vertigo control 2, 1
• Consider benzodiazepines cautiously for associated anxiety, but avoid prolonged use due to dependence risk and impaired vestibular compensation 2, 1

Critical pitfall: Do not continue vestibular suppressants between attacks, as this prevents the brain from compensating for vestibular dysfunction 1

Maintenance Pharmacotherapy (After Lifestyle Modifications)

• Offer diuretics as primary maintenance therapy to modify electrolyte balance in the endolymph and reduce its volume 2, 1
• Consider betahistine (a histamine analogue that increases inner ear vasodilation), though recent evidence including the BEMED trial showed no significant difference versus placebo 2
• Titrate down or stop medications once symptoms subside, as studies show variable treatment windows from 10 days to 24 years 4

The evidence for betahistine is questionable based on recent high-quality trials, making diuretics the more reliable maintenance option 2

Intratympanic Therapies for Non-Responders

When non-invasive treatments fail after adequate trial:

• Offer intratympanic steroids first for patients with active disease, providing 85-90% improvement in vertigo symptoms versus 57-80% with conventional therapy 2, 1

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

• Reserve intratympanic gentamicin for patients with persistent vertigo who have failed conservative therapies and intratympanic steroids 2, 1

  • Achieves complete vertigo control in approximately 73.6% of patients 2, 1
  • Carries significant risk of hearing loss that varies by administration protocol 2

Vestibular Rehabilitation

• Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy 2, 1
• This promotes central vestibular compensation and improves balance, gait, and gaze stability 1
• Do not use for acute attack management, only for inter-attack periods 2

Surgical Options (Last Resort Only)

Reserve surgery 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 in refractory cases 5
• Labyrinthectomy only for patients with non-usable hearing who have failed all other therapies 2, 5

Critical consideration: 10-25% of cases eventually become bilateral, so avoid ablative procedures in the only hearing ear 2

Treatment NOT Recommended

• Do not prescribe positive pressure therapy (Meniett device), as multiple systematic reviews and RCTs show no significant difference compared to placebo for vertigo control 4, 2, 1
• The device may actually worsen hearing levels based on moderate quality evidence from two studies 4

Monitoring Requirements

• Obtain audiometry at diagnosis and regularly during follow-up to document the characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 2, 5
• Document changes in vertigo frequency/severity, tinnitus, and hearing loss after each intervention 2, 1
• Assess quality of life impact using validated instruments 2
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages, which occur suddenly without warning 2

Critical Pitfalls to Avoid

• Do not continue vestibular suppressants for maintenance, as this prevents central compensation 1
• Do not perform ablative procedures without considering bilateral disease risk (10-25% of cases) 2
• Do not expect hearing restoration, as hearing loss often worsens over time despite treatment interventions 5
• Recognize the 60% placebo response rate in clinical trials when evaluating treatment efficacy 2