What is the recommended duration of betahistine therapy for Ménière’s disease‑related vertigo and tinnitus?

Duration of Betahistine Therapy

Betahistine should be taken for a minimum of 3 months initially, with reassessment at 6-9 months to determine if continuation is warranted; if no improvement occurs by 6-9 months, discontinue the medication as further therapy is unlikely to provide benefit. 1

Initial Treatment Period

• Start betahistine at 48 mg daily (either as 24 mg twice daily or as a single 48 mg modified-release tablet) and continue for at least 3 months to properly evaluate therapeutic efficacy 1
• The 3-month minimum is necessary because vestibular symptoms may take time to respond, and shorter treatment periods do not allow adequate assessment of benefit 1
• Higher doses (144 mg/day) show no advantage over the standard 48 mg/day dose 1

Reassessment Timeline

• Conduct formal reassessment at 6-9 months to evaluate symptom improvement, frequency of vertigo attacks, and medication side effects 1
• If no improvement is evident by 6-9 months, betahistine should be discontinued as continued therapy beyond this point is unlikely to provide benefit 1
• Patients showing partial response or stable symptoms at 3 months should continue treatment through the 6-9 month reassessment period 1

Important Evidence Limitations

The American Academy of Otolaryngology-Head and Neck Surgery explicitly states they cannot make a definitive recommendation for betahistine use in Ménière's disease due to conflicting evidence 2, 1, 3. The high-quality BEMED trial found no significant difference between betahistine and placebo in reducing vertigo attacks over 9 months 2, 1. Despite this, betahistine may be offered as maintenance therapy to reduce symptoms or prevent attacks, recognizing the balance of benefits and harms 4.

Clinical Decision Algorithm

1. Confirm diagnosis: Ensure patient meets criteria for definite Ménière's disease (≥2 episodes of vertigo lasting 20 minutes to 12 hours, audiometrically documented fluctuating sensorineural hearing loss, fluctuating aural symptoms) 3

2. Screen for contraindications: Betahistine is absolutely contraindicated in pheochromocytoma and should be used with caution in asthma and active peptic ulcer disease 2, 1, 3

3. Initiate treatment: Start 48 mg daily for minimum 3 months 1

4. First reassessment at 3 months: Evaluate for any symptom improvement, side effects (headache, balance disorder, nausea, upper GI symptoms) 2, 1

5. Continue to 6-9 months if: Patient shows partial response or stable symptoms 1

6. Discontinue if: No improvement by 6-9 months, as further benefit is unlikely 1

Common Pitfalls to Avoid

• Do not stop treatment prematurely (before 3 months) as this prevents adequate assessment of efficacy 1
• Do not continue indefinitely without reassessment - the 6-9 month checkpoint is critical for determining if ongoing therapy is justified 1
• Do not escalate to higher doses (>48 mg daily) as studies show no additional benefit 1
• Do not use betahistine for acute vertigo attacks - medications with direct antiemetic effects like prochlorperazine are preferred for acute episodes 1