How should an adult with an acute Meniere's vertigo attack be treated?

Treatment for Acute Ménière's Vertigo

For an acute Ménière's vertigo attack, offer a limited course of vestibular suppressants such as meclizine (25-100 mg daily in divided doses) or other antihistamines, combined with antiemetics as needed for nausea, but only during the active attack—not for long-term use. 1, 2

Acute Attack Management

First-Line Pharmacotherapy

Vestibular suppressants are the cornerstone of acute symptom control:

• Antihistamines are the primary vestibular suppressants recommended, with meclizine being FDA-approved at doses of 25-100 mg daily in divided doses for vertigo associated with vestibular system diseases 2
• Benzodiazepines can be added for severe anxiety associated with acute attacks, but use with extreme caution due to significant risk of drug dependence 1
• Antiemetics should be prescribed concurrently to manage nausea and vomiting during acute episodes 1

Important Limitations and Warnings

These medications are for acute attacks only—not for prevention or long-term use:

• The American Academy of Otolaryngology-Head and Neck Surgery explicitly recommends vestibular suppressants only during active Ménière's attacks, not between episodes 1
• Anticholinergic agents (scopolamine, atropine, glycopyrrolate) can suppress acute vertigo but are not commonly prescribed due to significant side effects including blurred vision, dry mouth, dilated pupils, urinary retention, and sedation 1
• Benzodiazepines carry substantial dependence risk and should be limited to short courses 1

Medication-Specific Precautions

Meclizine requires careful patient selection:

• Contraindicated in patients with hypersensitivity to meclizine 2
• Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 2
• May cause drowsiness—patients should avoid driving or operating dangerous machinery 2
• Common adverse reactions include drowsiness, dry mouth, headache, fatigue, and vomiting 2

Concurrent Patient Education During Acute Attack

Even during an acute episode, begin educating patients about trigger identification and lifestyle modifications:

• Explain that dietary modifications (sodium restriction to 1500-2300 mg daily, limiting caffeine and alcohol) may reduce future attack frequency 1, 3
• Stress management through adequate sleep, exercise, and relaxation techniques can help prevent future episodes 1, 3
• Encourage keeping a symptom diary to identify personal triggers, which vary significantly between patients 1, 3

What NOT to Do

Avoid these common pitfalls:

• Do not prescribe vestibular suppressants for continuous use between attacks—they are ineffective for prevention and may delay vestibular compensation 1
• Do not use positive pressure therapy (Meniett device), as multiple systematic reviews show no benefit over placebo and may worsen hearing 3
• Do not prescribe vestibular rehabilitation during acute attacks—it is only useful for chronic imbalance between episodes 3

Follow-Up Planning

After the acute attack resolves, transition to maintenance therapy:

• If attacks are frequent (weekly or monthly), consider maintenance therapy with diuretics as first-line pharmacologic treatment 3
• Betahistine has questionable efficacy based on recent high-quality trials (BEMED trial showed no significant difference versus placebo) 3
• For patients failing conservative measures and diuretics after 3-6 months, consider intratympanic steroid injections, which achieve vertigo improvement in 85-90% of cases 3

Special Populations

Adjust treatment approach based on comorbidities:

• In pregnancy, avoid diuretics and intratympanic gentamicin; rely on dietary measures and short courses of vestibular suppressants during acute attacks only 3
• In patients with renal or cardiac disease, exclude diuretic therapy and consider intratympanic steroids earlier 3
• Monitor for bilateral disease development (occurs in 10-25% of cases), which impacts long-term surgical decision-making 3