What are the symptoms of Meniere's disease and which are the most likely to occur?

Symptoms of Ménière's Disease

The most likely symptoms of Ménière's disease are episodic vertigo lasting 20 minutes to 12 hours, fluctuating low- to mid-frequency sensorineural hearing loss, tinnitus, and ear fullness in the affected ear—all four symptoms together form the classic tetrad that defines this condition. 1

Core Diagnostic Symptoms (Most Likely)

The American Academy of Otolaryngology-Head and Neck Surgery defines the essential symptom complex for definite Ménière's disease:

Vertigo (Hallmark Symptom)

• Spontaneous attacks of true rotational vertigo (sensation of spinning or self-motion) lasting specifically 20 minutes to 12 hours per episode 1
• Must occur as two or more discrete episodes to meet diagnostic criteria 1
• The vertigo is not positional and occurs spontaneously, distinguishing it from benign paroxysmal positional vertigo 1
• Important caveat: Elderly patients with long-standing disease may present with vague dizziness or vestibular disturbance rather than frank spinning vertigo 1

Fluctuating Hearing Loss (Defining Feature)

• Low- to mid-frequency sensorineural hearing loss documented on audiometry 1, 2
• The fluctuating nature is pathognomonic—hearing worsens during attacks and may partially recover between episodes 1, 2
• Must be documented before, during, or after at least one vertigo episode 1
• Progressive pattern: Over time, hearing loss extends to involve all frequencies and becomes less fluctuating and more permanent 1, 2

Tinnitus

• Occurs as a fluctuating aural symptom in the affected ear 1
• Often accompanies or precedes vertigo attacks 3, 4
• May vary in intensity with disease activity 5

Aural Fullness (Ear Pressure)

• Sensation of pressure or fullness in the affected ear 1
• Fluctuates with disease activity, often worsening before or during attacks 1, 3
• Part of the classic symptom tetrad 3, 4, 6

Additional Associated Symptoms

Nausea and Vomiting

• Commonly accompany acute vertigo attacks 3, 7
• Result from the severity of vestibular disturbance 4

Imbalance

• May persist between acute attacks as ongoing unsteadiness 1
• Distinct from episodic vertigo—represents chronic vestibular dysfunction 1

Drop Attacks (Tumarkin's Otolithic Crisis)

• Sudden falls without loss of consciousness during discrete attacks 1
• Occur in later stages of disease, not present in every patient 1
• No warning before the fall occurs 1

Headache

• Found during attacks in some patients 8
• May overlap with vestibular migraine, which co-occurs at high rates 4

Symptom Timing and Pattern Recognition

Critical distinction: Patients must describe true vertigo (spinning sensation), not vague dizziness, lightheadedness, or presyncope, which are inconsistent with Ménière's disease 1. Many patients use "dizziness" imprecisely, leading to misdiagnosis 1.

Duration Specificity

• Definite Ménière's disease: Vertigo episodes last 20 minutes to 12 hours 1
• Probable Ménière's disease: Episodes may extend up to 24 hours 1
• Episodes lasting seconds suggest benign paroxysmal positional vertigo instead 1
• Episodes lasting days suggest labyrinthitis or vestibular neuritis 1

Bilateral Involvement

• 10% to 25% of cases eventually affect both ears over time 2, 8
• Bilateral disease complicates the clinical course and worsens long-term hearing outcomes 2

Common Pitfalls in Symptom Recognition

Avoid misdiagnosis by distinguishing from mimics:

• Vestibular migraine: Attacks may be shorter (minutes) or longer (>24 hours) than Ménière's disease; hearing loss is less likely; patients have migraine history 1
• Vestibular schwannoma: Chronic imbalance rather than episodic vertigo; hearing loss does not fluctuate 1
• Labyrinthitis/vestibular neuritis: Prolonged vertigo (>24 hours), not episodic and not fluctuating 1
• Stroke: Permanent deficits that don't fluctuate; may have other neurologic signs; usually no hearing loss 1

Key clinical teaching point: Educate patients to clearly describe their symptoms—a confident description of spinning is typically specific for inner ear dysfunction and Ménière's disease 1. Ask detailed questions about onset (spontaneous vs. provoked), exact duration, and concurrent otologic symptoms 1.