In an adult with recurrent vertigo, how can I differentiate endolymphatic hydrops (Meniere’s disease) from vestibular migraine, and what are the first‑line diagnostic tests and treatments for each?

Differentiating Endolymphatic Hydrops (Ménière's Disease) from Vestibular Migraine

The key distinction is that Ménière's disease requires documented low-to-mid-frequency sensorineural hearing loss on audiometry with vertigo attacks lasting 20 minutes to 12 hours, while vestibular migraine presents with vertigo episodes lasting 5 minutes to 72 hours accompanied by migraine features (photophobia, phonophobia, visual aura) in at least 50% of episodes, typically without significant hearing loss. 1, 2

Clinical Differentiation Algorithm

Step 1: Assess Episode Duration and Pattern

• Ménière's disease: Vertigo attacks last specifically 20 minutes to 12 hours, with spontaneous onset 1
• Vestibular migraine: Episodes range from 5 minutes to 72 hours (30% last minutes, 30% hours, 30% days, 10% seconds with repeated attacks) 1, 3

Step 2: Evaluate Auditory Symptoms

• Ménière's disease: Fluctuating low-to-mid-frequency sensorineural hearing loss documented on audiometry before, during, or after vertigo episodes; prominent tinnitus and aural fullness in the affected ear 1
• Vestibular migraine: Hearing loss is mild, absent, or stable over time; bilateral auditory symptoms more common than unilateral; patients describe difficulty processing sound rather than true hearing loss 2, 3

Step 3: Identify Migraine Features

• Vestibular migraine: At least 50% of episodes must include headache with migraine characteristics (unilateral, pulsating, moderate-to-severe intensity, worsened by activity), photophobia, phonophobia, or visual aura (bright lights, zigzag lines lasting 5-60 minutes) 1, 2, 3
• Ménière's disease: Headache may occur but is not a defining feature; less photophobia than vestibular migraine 1

Step 4: Consider Age and Presentation

• Ménière's disease: Later age of onset, more prominent tinnitus and aural fullness 4
• Vestibular migraine: Often history of migraine; more vomiting and aura 4

First-Line Diagnostic Tests

For Ménière's Disease:

• Audiometry (mandatory): Must document low-to-mid-frequency sensorineural hearing loss with fluctuation 1
• Vestibular testing: Abnormal caloric testing and vestibular evoked myogenic potentials support diagnosis 4
• MRI with gadolinium-enhanced inner ear imaging: Can visualize endolymphatic hydrops (all Ménière's patients show significant vestibular hydrops bilaterally or unilaterally, versus absent or minimal in vestibular migraine) 5, 6

For Vestibular Migraine:

• Clinical diagnosis: Based on history meeting diagnostic criteria (≥5 episodes with vestibular symptoms lasting 5 minutes-72 hours, migraine features in ≥50% of episodes, current or previous migraine history) 2, 3
• Audiometry: To rule out significant hearing loss characteristic of Ménière's disease 1
• Neuroimaging (MRI brain): Only if red flags present (downbeating nystagmus on Dix-Hallpike, direction-changing nystagmus, gaze-holding nystagmus, dysarthria, dysmetria, dysphagia, sensory/motor loss, Horner's syndrome) 2

First-Line Treatments

For Ménière's Disease:

• Dietary/lifestyle modifications: Sodium restriction, limit caffeine/alcohol/nicotine, adequate hydration, stress management, regular sleep 1
• Medical therapy: Diuretics and vestibular suppressants for acute attacks (not long-term use) 1
• Goals: Prevent/reduce vertigo frequency and severity, preserve hearing, improve quality of life 1

For Vestibular Migraine:

• Lifestyle modifications first: Stress reduction, regular sleep schedule, dietary triggers avoidance, regular exercise 2
• Preventive medications (when symptoms occur ≥2 days/month): Beta blockers (propranolol, metoprolol, atenolol) as first-line; topiramate 50-100 mg daily (especially if obese); candesartan (if hypertensive) 2
• Acute treatment: Vestibular suppressants (diphenhydramine, meclizine) for symptom relief; triptans for concurrent headache 2
• Assess efficacy: After 2-3 months at therapeutic dose; consider pausing after 6-12 months of successful control 2

Critical Pitfalls to Avoid

Diagnostic Pitfalls:

• 35% of Ménière's patients also meet criteria for vestibular migraine 1—when uncertain, proceed with noninvasive therapeutic trials before any surgical or ablative interventions 1
• Do not perform destructive interventions (gentamicin, labyrinthectomy) until Ménière's disease is definitively confirmed with documented hearing loss and failure of conservative management 1
• Loss of consciousness never occurs in either condition—if present, evaluate for alternative diagnoses (stroke, cardiac causes) 1, 7, 3

Treatment Pitfalls:

• Avoid long-term vestibular suppressants in vestibular migraine—they are not recommended for chronic management 2
• Do not use opioids, barbiturates, or oral ergot alkaloids due to dependency risk and medication overuse headache 2
• Limit acute medications: Simple analgesics <15 days/month, triptans <10 days/month to prevent medication overuse headache 2
• Do not abandon treatment prematurely—efficacy takes weeks to months to establish 2

Management Strategy When Diagnosis Uncertain:

When differentiation is difficult despite testing, prioritize conservative management with lifestyle modifications and preventive medications appropriate for vestibular migraine, as these are non-destructive and reversible, while reserving ablative Ménière's treatments only for cases with confirmed progressive hearing loss and failed conservative therapy 1