What are the treatment options for a patient with Meniere’s disease experiencing dizziness/vertigo?

Treatment of Menière's Disease for Dizziness/Vertigo

For acute vertigo attacks in Menière's disease, offer a limited course of vestibular suppressants (meclizine 25-100 mg daily or other antihistamines/benzodiazepines) only during attacks, while implementing dietary modifications (sodium restriction to 1500-2300 mg/day, caffeine and alcohol limitation) as foundational therapy. 1, 2

Acute Vertigo Management During Attacks

Vestibular suppressants should be used only during active vertigo episodes, not continuously. 1

• Meclizine (antihistamine): 25-100 mg daily in divided doses, FDA-approved for vertigo associated with vestibular disorders 3
• Other antihistamines: Dimenhydrinate or similar agents can suppress acute attacks 1
• Benzodiazepines: Can be used for severe attacks with associated anxiety, but carry significant risk of dependence and should be limited to short-term use only 1
• Anticholinergics (scopolamine): Block muscarinic receptors to suppress vertigo but cause significant side effects (blurred vision, dry mouth, urinary retention, sedation) and are not commonly prescribed due to toxicity risk with prolonged use 1

Critical caveat: There is insufficient evidence demonstrating superiority of any specific vestibular suppressant class over another. 1 The choice depends on side effect profile and patient-specific contraindications (avoid anticholinergics in glaucoma, prostate enlargement, asthma). 3

Dietary and Lifestyle Modifications (First-Line Foundation)

These interventions should be implemented immediately at diagnosis as they have preponderance of benefit over harm, despite limited high-quality evidence. 1

• Sodium restriction: 1500-2300 mg daily (American Heart Association guidelines) to reduce endolymphatic fluid accumulation 1, 2
• Caffeine limitation: Patients with Menière's have higher caffeine intake than controls; restriction shows benefit in observational studies 1, 2
• Alcohol avoidance: Can trigger attacks in susceptible patients 1, 2
• Allergy management: Allergies contribute to symptoms in up to 30% of patients; identify and treat appropriately 1, 2
• Stress management: Implement relaxation techniques, regular exercise, adequate sleep (6-7 hours in darkness) 1, 2
• Symptom diary: Track triggers to identify personal patterns 2

Important consideration: The evidence for dietary modifications is Grade C quality (limited RCTs), but the interventions are low-risk and may improve quality of life. 1 Referral to a registered dietitian improves compliance and outcomes. 1

Maintenance Pharmacotherapy (Second-Line)

If vertigo attacks persist despite dietary modifications, add maintenance therapy with diuretics as the most reliable option. 2, 4

• Diuretics: Modify electrolyte balance in endolymph and reduce its volume; supported by observational studies and Cochrane reviews with moderate evidence quality 2, 4
• Betahistine: A histamine analogue that increases inner ear vasodilation, but recent high-quality evidence (BEMED trial) shows no significant difference versus placebo, making its efficacy questionable 2, 5

Critical decision point: Diuretics are the more reliable maintenance option given the questionable efficacy of betahistine in recent trials. 2 Titrate down or stop medications once symptoms subside. 2

Intratympanic Therapies (Third-Line for Refractory Disease)

For patients failing conservative measures after several months, escalate to intratympanic interventions. 2, 4

• Intratympanic steroids: Offer 85-90% improvement in vertigo symptoms (versus 57-80% with conventional therapy), improved quality of life, and faster return to work 2, 4, 5

  • Risks: Hearing loss, tympanic membrane perforation, persistent imbalance 4

• Intratympanic gentamicin: For persistent vertigo after failed non-ablative therapy; achieves complete vertigo control in approximately 73.6% of cases 2

  • Mechanism: Reduces vestibular function in treated ear (complete ablation not typically required) 6
  • Risk: Variable hearing loss depending on administration method 2

Critical warning: Avoid ablative procedures in patients with bilateral disease (10-25% eventually become bilateral) or in the only hearing ear. 4

Vestibular Rehabilitation

Offer vestibular rehabilitation for chronic imbalance between attacks or following ablative therapy, NOT for acute vertigo management. 1, 2

• Benefits include improved symptom control, reduced fall risk, and better functional outcomes 2
• Should not be used during acute attacks 1

Surgical Options (Fourth-Line for Severe Refractory Cases)

Reserve for patients who have failed all medical therapies. 4

• Hearing-preserving procedures: Endolymphatic sac decompression, vestibular nerve section (for usable hearing: Class A, B, or C) 4, 5
• Ablative procedures: Labyrinthectomy (for non-usable hearing: Class D) 4, 5

Treatment NOT Recommended

Do not prescribe positive pressure therapy (Meniett device)—multiple systematic reviews and RCTs show no significant difference compared to placebo. 2, 4

Monitoring Requirements

• Obtain audiometry at diagnosis and regularly during follow-up to document characteristic low-to-mid-frequency sensorineural hearing loss and monitor progression 4, 5
• Document changes in vertigo frequency/severity, tinnitus, and hearing loss after each intervention 2, 4
• Assess quality of life impact using validated instruments 4, 5
• Watch for drop attacks (Tumarkin's otolithic crisis) in later disease stages—sudden falls without warning or loss of consciousness 4, 5

Common Pitfalls to Avoid

• Do not use vestibular suppressants continuously—they are only for acute attacks to avoid dependence and side effects 1
• Do not ignore the 60% placebo response rate in clinical trials when assessing treatment efficacy 4
• Do not perform ablative surgery without considering bilateral disease risk (10-25% become bilateral over time) 4
• Recognize that hearing loss often worsens despite treatment—complete restoration is not currently possible 4, 5