What is the recommended treatment and dosage of Betahistine (Betaghistine) for an adult patient with a history of vestibular or auditory symptoms, such as vertigo, tinnitus, and hearing loss, associated with Meniere's disease or other inner ear disorders?

Betahistine for Menière's Disease

Direct Recommendation

Start betahistine 48 mg daily (24 mg twice daily or single modified-release tablet) for maintenance therapy in patients with definite or probable Menière's disease, continuing for at least 3 months with reassessment at 6-9 months, though be aware that the highest quality evidence (BEMED trial) shows no significant benefit over placebo. 1

Critical Evidence Caveat

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states they cannot make a definitive recommendation for betahistine due to conflicting evidence. 1, 2 The most recent high-quality BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks over 9 months. 1, 2 Despite this, betahistine remains widely used and may be offered as maintenance therapy with appropriate patient counseling about uncertain efficacy. 3, 1

Diagnostic Confirmation Required

Before prescribing betahistine, confirm the patient meets criteria for definite Menière's disease: 2 or more episodes of vertigo lasting 20 minutes to 12 hours PLUS fluctuating or nonfluctuating sensorineural hearing loss, tinnitus, or pressure in the affected ear. 3 For probable Menière's disease, vertigo episodes may last up to 24 hours. 3

Ensure true rotational vertigo (spinning sensation) rather than vague dizziness or lightheadedness, as betahistine is indicated specifically for vestibular disorders. 1

Absolute Contraindications

Never prescribe betahistine in patients with pheochromocytoma. 3, 1, 2

Relative Contraindications and Cautions

Use betahistine cautiously in patients with: 3, 1, 2

• Active asthma
• Active peptic ulcer disease
• History of peptic ulcer disease

Dosing Protocol

Initial dose: 48 mg daily, administered as either 24 mg twice daily or a single 48 mg modified-release tablet. 1

Duration: Minimum 3 months to properly evaluate therapeutic efficacy. 1

Reassessment timeline: Evaluate response at 6-9 months. 1 If no improvement occurs by 6-9 months, discontinue betahistine as continued therapy is unlikely to provide benefit. 1

Higher doses: 144 mg/day shows no advantage over the standard 48 mg/day dose. 1

Expected Outcomes and Monitoring

Document changes in: 3

• Vertigo frequency and severity
• Tinnitus
• Hearing loss
• Aural fullness
• Quality of life measures

Consider obtaining follow-up audiograms to monitor hearing function. 3

Italian consensus experts (87% agreement) consider betahistine useful for reducing dizziness and vertigo during the intercritical phase of disease, but less effective during acute attacks. 4

Common Side Effects

Patients may experience: 1, 2

• Headache
• Balance disorder
• Nausea
• Upper gastrointestinal symptoms
• Nasopharyngitis
• Feeling hot
• Eye irritation
• Palpitations

Alternative and Adjunctive Treatments

For acute vertigo attacks: Offer a limited course of vestibular suppressants (medications with direct antiemetic effects like prochlorperazine are preferred over betahistine for acute episodes). 3, 1

Combination therapy: Intratympanic steroids combined with oral betahistine may improve vertigo control (73% improvement versus 44% without betahistine). 5, 1

Alternative maintenance therapy: Diuretics may be offered as an alternative or in addition to betahistine. 3

For refractory disease: Intratympanic gentamicin provides 70-87% complete vertigo control, though with 12.5-15.4% risk of hearing loss. 5, 1 Titration therapy with gentamicin achieves 81.7% vertigo control. 5

Vestibular rehabilitation: Consider for patients who have failed less definitive therapy and have nonusable hearing. 3

Important Clinical Pitfalls

Do not use betahistine for benign paroxysmal positional vertigo (BPPV) - this is a different condition requiring different treatment. 3

Screen for vestibular migraine: This commonly mimics Menière's disease. 5 Vestibular migraine patients may describe "hearing loss" as difficulty processing sound rather than hearing it, often have bilateral auditory complaints, and experience visual auras, motion intolerance, and light sensitivity. 5 Vertigo duration in vestibular migraine may be shorter (<15 minutes) or longer (>24 hours) than typical Menière's attacks. 5

Patient preference is critical given the uncertain evidence for benefit. 3, 2 Discuss the conflicting evidence openly with patients before initiating therapy.