What are the treatment options for Meniere's disease?

From the Guidelines

Meniere's disease treatment should focus on managing symptoms and preventing vertigo attacks, with initial treatment including lifestyle modifications and medications such as diuretics, anti-vertigo medications, and anti-nausea drugs, as recommended by the 2020 clinical practice guideline 1. The goals of treatment are to prevent or reduce the severity and frequency of vertigo attacks, relieve or prevent hearing loss, tinnitus, and aural fullness, and improve overall quality of life (QOL) 1. Key treatment approaches include:

• Lifestyle modifications, such as reducing salt intake to 1500-2000mg daily, limiting caffeine and alcohol, stopping smoking, and managing stress
• Medications, including diuretics like hydrochlorothiazide (25-50mg daily) or acetazolamide to reduce inner ear fluid, anti-vertigo medications such as meclizine (25mg every 4-6 hours as needed) or diazepam (2-5mg) during attacks, and anti-nausea drugs like ondansetron (4-8mg) or promethazine (12.5-25mg)
• For persistent symptoms, intratympanic steroid injections with dexamethasone may be used
• In severe cases unresponsive to medical management, surgical options include endolymphatic sac decompression to reduce pressure, vestibular nerve section to stop vertigo while preserving hearing, or labyrinthectomy (which eliminates vertigo but sacrifices hearing) 1. Regular follow-up with an otolaryngologist is essential to monitor symptoms and adjust treatment as needed, and patient education on the natural history, measures for symptom control, treatment options, and outcomes is also crucial 1.

From the Research

Treatment Options for Meniere's Disease

• Conservative measures, including a low salt diet, avoidance of stress and caffeine, and sleep hygiene, are the initial steps in treating Meniere's disease 2
• Medical therapy with a diuretic is the usual next step, with studies suggesting that oral diuretic therapy may be beneficial in managing the disease 3
• If diuretic therapy fails, options such as intratympanic (IT) steroids and betahistine may be considered 2
• Other treatment options include the Meniett device, endolymphatic sac surgery, and ablative therapies like intratympanic gentamicin 2

Medical Management and Rationale for Vestibular Preservation

• Nonablative therapy options, such as intratympanic steroids and endolymphatic shunt surgery, are preferred prior to ablative techniques like intratympanic gentamicin 4
• Recognizing concurrent migraine symptoms may aid in medical therapy and underscore the importance of preserving vestibular function 4
• A low-salt diet has been shown to be effective in treating Meniere's disease, with a possible mechanism involving increased endolymph absorption in the endolymphatic sac due to elevated aldosterone levels 5

Pharmacotherapy and Combination Therapies

• Betahistine is a common medication used to treat Meniere's disease, but its high first-pass effect may limit its effectiveness 6
• Combining betahistine with the MAO-B inhibitor selegiline may allow for lower dosages of betahistine to be effective, potentially reducing side effects 6
• This combination therapy may be an alternative to high-dosage monotherapy with betahistine, although further studies are needed to confirm its efficacy 6