Medical treatment

Initially majority of patients will respond to lifestyle interventions and a trial of betahistines for three months

Managing an acute attack (1)

• the patient should lay down on a firm surface during the acute attack
• should stay as motionless as possible, with the eyes open and fixed on a stationary object
• drinking or sipping water should be avoided (this may cause vomiting)
• the patient should be kept like this until the severe vertigo is passed
• may get up very slowly, once the vertigo disappears.
• during an acute attack of Meniere's disease, the patient is likely to vomit
  
  
• oral medication used to suppress the symptoms of acute vestibular attacks (vestibular sedatives) include
  • cinnarizine, 15-30 mg t.d.s. or
  • phenothiazines such as prochlorperazine 5-10mg tds - regular long term basis is not recommended, or
  • promethazine, cyclizine, or,
  • metoclopramide, or,
  • benzodiazepine – can be used with caution for short periods

Measures for prevention of acute attacks

• lifestyle interventions (dietary control) - the goal is to provide stable body fluid/blood levels to avoid secondary fluctuations in the inner ear fluid
  • food and fluid intake should be even throughout the day
  • foods or fluids that have a high salt content should be avoided
  • there should be adequate intake of fluids daily
    • may contain water, milk and low-sugar fruit juices
  • caffeine-containing fluids and foods (coffee, tea and chocolate) should be avoided.
  • alcohol intake should be limited to one glass of beer or wine each day
  • foods containing MSG (monosodium glutamate)also should be avoided
  • reducing or stopping smoking
    
    
• medical management
  • betahistine (2)
    • a starting dose of 16 mg three times a day will result in a reduction of the frequency and severity of attacks
    • however there is limited evidence for a strong effect of betahistine in preventing attacks
      
      
  • diuretics (3)
    • although there is lack of evidence to support their use, diuretics may sometimes be offered to patients based on the biological model of endolymphatic hydrops
      
      
  • corticosteroids (4)
    • both oral steroids and intratympanic steroid injections have been used in the treatment of acute and chronic symptoms
      
      
  • medical ablation (5)
    • used in patients with intractable vertigo
    • intratympanic use of aminoglycosides (gentamicin) to relieve vertigo and preservation of hearing

Other treatment options used in Meniere's disease include:

• vestibular rehabilitation (6)
  • physical therapy used to improve vestibular function and mechanisms of central adaptation and compensation
  • may include Cawthorne-Cooksey exercises and low-impact exercise, such as cycling or walking
  • useful in patients with stable, non-fluctuating vestibular loss
• adjunctive therapy - psychological or psychiatric intervention, e.g.- cognitive behavioural therapy, and techniques such as relaxation and breathing exercises
• pressure pulse treatment
  • is a non invasive method occasionally used for intractable vertigo in some patients with Meniere’s disease where positive pressure is provided through a pulse-generator into the ear canal. However - the American Academy of Otolaryngology 2020 guidelines recommend against the use of positive pressure therapy in patients with Meniere's (7)

Reference:

1. Nevoux J, Barbara M, Dornhoffer J, et al; International consensus (ICON) on treatment of Meniere's disease. Eur Ann Otorhinolaryngol Head Neck Dis. 2018 Feb;135(1S):S29-S32.
2. Casani AP, Guidetti G, Schoenhuber R; Report from a Consensus Conference on the treatment of Meniere's disease with betahistine: rationale, methodology and results. Acta Otorhinolaryngol Ital. 2018 Oct;38(5):460-467.
3. Webster KE, Galbraith K, Harrington-Benton NA, et al. Systemic pharmacological interventions for Ménière's disease. Cochrane Database Syst Rev. 2023 Feb 23;2(2):CD015171.
4. Phillips JS, Westerberg B. Intratympanic steroids for Ménière's disease or syndrome. Cochrane Database Syst Rev. 2011 Jul 06;(7):CD008514.
5. Postema RJ et al. Intratympanic gentamicin therapy for control of vertigo in unilateral Menire's disease: a prospective, double-blind, randomized, placebo-controlled trial. Acta Otolaryngol. 2008 Aug;128(8):876-80
6. Gottshall KR, Hoffer ME, Moore RJ, et al. The role of vestibular rehabilitation in the treatment of Meniere's disease. Otolaryngol Head Neck Surg. 2005 Sep;133(3):326-8.
7. Basura GJ, Adams ME, Monfared A, et al. Clinical practice guideline: Ménière's disease. Otolaryngol Head Neck Surg. 2020 Apr;162(suppl 2):S1-55.