Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

all patients

1st line – dietary changes and lifestyle modification

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ACUTE
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all patients
1st line – 

dietary changes and lifestyle modification

All patients should be educated on dietary changes and lifestyle modification. Patients should be advised to restrict salt intake to 1500 to 2300 mg/day, as this is thought to prevent sodium-related water retention and redistribution into the endolymphatic system.[21][52]​​​ Although there are no randomized controlled trials to document the benefits of low-salt diet on the treatment of meniere disease (MD), patients often report exacerbation of their symptoms or even precipitation of an attack after a salty meal.[52][53]​ 

Limiting caffeine intake, reducing alcohol consumption, ceasing smoking, and managing stress are also advisable, as these may trigger an attack. However, there is no evidence from randomized controlled trials to support or refute the restriction of salt, caffeine, or alcohol intake in patients with MD.[53][54]

Such dietary changes may be the only necessary treatment required in the early stages of the disease.

Consider – diuretic

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ACUTE
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all patients
Consider – 

diuretic

Treatment recommended for SOME patients in selected patient group

Diuretics are believed to reduce the volume of the endolymph and may be offered for maintenance therapy.[21][55]​ 

The most commonly used diuretics in the treatment of MD are thiazides with or without potassium-sparing diuretics (e.g., hydrochlorothiazide/triamterene) and acetazolamide.[21]

If the patient remains symptom-free for 6 months, diuretics may be slowly tapered and restarted if required. If there is no response, the patient should be changed to the alternative diuretic. These medications should not be used in patients with a known or suspected reaction to sulfonamides.

The evidence of the efficacy of diuretics on MD is controversial, and direct evidence of its efficacy on disease progression is lacking in the literature.​[2]​ However, diuretics are still considered by many physicians to be first-line treatment in all patients with MD.

Primary options

triamterene/hydrochlorothiazide: 37.5 mg (triamterene)/25 mg (hydrochlorothiazide) orally once daily

-- OR --

acetazolamide: 250 mg orally (regular-release) twice daily

Plus – vestibular suppressant, antiemetic, or corticosteroid

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ACUTE
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all patients
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symptomatic vertigo
Plus – 

vestibular suppressant, antiemetic, or corticosteroid

Treatment recommended for ALL patients in selected patient group

Symptoms of individual and acute vertigo spells can be treated with vestibular suppressants and antiemetics. However, much of the effect is from the sedative action of these drugs.

The literature lacks randomized controlled trials assessing the effects of these medications for acute attacks of MD.

Commonly used treatments include antihistamines (e.g., meclizine, dimenhydrinate, promethazine), benzodiazepines (e.g., diazepam), and phenothiazines (e.g., prochlorperazine).[57] Diazepam should only be used in acute attacks.[21] It should be prescribed at low doses where possible, and long-term prescription avoided due to the risk of dependency. Prochlorperazine is a second-line treatment for patients with refractory nausea.

Oral corticosteroids may be used to treat acute attacks of vertigo, especially when accompanied by acute hearing loss and tinnitus. They are widely used because of their anti-inflammatory properties, although no randomized controlled trials are available to assess their efficacy in MD.[60] The dose, indications, and duration of corticosteroids used vary in the literature. Oral corticosteroids have very well-known adverse effects but are often tolerated at such a dose and for short durations.

Primary options

meclizine: 12.5 to 25 mg orally every 6 hours when required

OR

dimenhydrinate: 50 mg orally every 4-6 hours when required

OR

promethazine: 12.5 to 25 mg orally/rectally every 4-6 hours when required

Secondary options

diazepam: 2-10 mg orally every 4-6 hours when required

OR

prochlorperazine maleate: 5-10 mg orally every 6-8 hours when required

OR

prochlorperazine rectal: 25 mg rectally twice daily when required

Tertiary options

prednisone: 20 mg orally three times daily for 2-3 weeks, then gradually taper

Consider – intratympanic injection

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ACUTE
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all patients
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symptomatic vertigo
Consider – 

intratympanic injection

Treatment recommended for SOME patients in selected patient group

Intratympanic corticosteroids: there is wide variation in the dose used, frequency of administration, and method of application in the literature. Tympanic membrane perforation and infection can occur.

Intratympanic gentamicin: gentamicin (an aminoglycoside antibiotic) preferentially destroys the vestibular labyrinth when injected into the middle ear, resulting in chemical labyrinthectomy. In one prospective, double-blind, randomized, placebo-controlled clinical trial, intratympanic gentamicin treatment was found to reduce the score of vertigo severity and perceived aural fullness in the treatment group.[77] Evidence suggests that intratympanic gentamicin injections improve vertigo symptoms, are well tolerated, and have a low incidence of severe hearing loss.[21]​ However, two systematic reviews in 2023 found that the efficacy of intratympanic gentamicin and corticosteroid injections in the treatment of patients with MD is unclear due to the uncertainty of available evidence.[78][79]

Primary options

dexamethasone sodium phosphate: consult specialist for guidance on intratympanic dose

OR

methylprednisolone sodium succinate: consult specialist for guidance on intratympanic dose

OR

gentamicin: consult specialist for guidance on intratympanic dose

Plus – nonpharmaceutical therapy

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ACUTE
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all patients
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symptomatic tinnitus
Plus – 

nonpharmaceutical therapy

Treatment recommended for ALL patients in selected patient group

Patients with severe, intractable tinnitus can receive relief with a number of modalities, such as tinnitus maskers, tinnitus retraining therapy (TRT), amplifications, medication, biofeedback, and neuromonics.[67]

Tinnitus maskers (white noise generators) are devices similar to hearing aids that fit behind the ear. They produce a quiet external sound that distracts the patient from the internal tinnitus noise. In one form of tinnitus masking, the level of the masker is increased until the patient's own tinnitus is rendered inaudible. In TRT the masker remains audible along with the patient's tinnitus, and the patient learns to adjust to the audible masking level along with his or her own tinnitus. Thus, both remain audible in a graduated situation where the patient learns to tolerate his or her own tinnitus while accepting the audible tinnitus masker.

TRT is counseling accompanied by white noise generators. TRT is a favored treatment, but it may take up to 18 months before full benefits are achieved.[64][65]

Neuromonics uses a customized neural stimulus combined with specific music, delivered through a coordinated program to interact with, interrupt, and desensitize tinnitus disturbance for long-term benefit.[66][67][68]

Amplifications (hearing aids) may help in masking the tinnitus.

Biofeedback techniques attempt to decrease the anxiety that is associated with the tinnitus. This can be achieved through relaxation techniques, hypnosis, and cognitive behavioral therapy.

Consider – antidepressant or benzodiazepine

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ACUTE
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all patients
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symptomatic tinnitus
Consider – 

antidepressant or benzodiazepine

Treatment recommended for SOME patients in selected patient group

Medications such as antidepressants (e.g., amitriptyline) and benzodiazepines (e.g., alprazolam) may help patients with intractable tinnitus, but are associated with adverse effects.[69] They should only be used if nonpharmaceutical treatments are unsuccessful and debilitating tinnitus persists.

Primary options

amitriptyline: 25-75 mg/day orally given in 1-3 divided doses

OR

alprazolam: 0.25 to 0.5 mg orally (immediate-release) three times daily

Plus – corticosteroid

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ACUTE
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all patients
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sudden hearing loss
Plus – 

corticosteroid

Treatment recommended for ALL patients in selected patient group

The dose, indications, and duration of oral corticosteroids used vary in the literature. Oral corticosteroids have very well known adverse effects but are often tolerated at such a dose and for short durations.

Intratympanic corticosteroids are used in patients with MD where systemic corticosteroids are contraindicated, or in patients who do not respond to oral corticosteroids. There is a wide variation in the dose used, frequency of administration, and method of application in the literature. Tympanic membrane perforation and infection can occur.

Primary options

prednisone: 20 mg orally three times daily for 2-3 weeks, then gradually taper

Secondary options

dexamethasone sodium phosphate: consult specialist for guidance on intratympanic dose

OR

methylprednisolone sodium succinate: consult specialist for guidance on intratympanic dose

ONGOING

persistent hearing loss

1st line – amplification (hearing aid) or assistive listening device

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ONGOING
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persistent hearing loss
1st line – 

amplification (hearing aid) or assistive listening device

Because hearing varies dramatically in these patients, access to expert audiologic personnel for reprogramming the hearing aid(s) is essential. Use of instruments incorporating algorithms to improve word recognition in noisy listening environments is also essential.

Amplification using fully digital hearing aids with variable digitally adjustable circuitry should be evaluated. The traditional view that amplification does not work for patients with MD is not based on experience with modern amplification.

New forms of directional microphones, digital signal processing circuitry, and wireless technology can provide significant benefits in helping MD patients to hear better in environments with competing noise.[70]

Assistive listening devices are a form of amplification for those with situational difficulties in hearing, and who are not yet ready or willing to use personal hearing aids.

Plus – intensive high-quality audiologic counseling

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ONGOING
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persistent hearing loss
Plus – 

intensive high-quality audiologic counseling

Treatment recommended for ALL patients in selected patient group

Intensive high-quality audiologic counseling is needed for patients with MD in the adjustment to, and acceptance of, amplification.

failure of medical and intratympanic therapies; hearing adequate

1st line – endolymphatic sac surgery

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ONGOING
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failure of medical and intratympanic therapies; hearing adequate
1st line – 

endolymphatic sac surgery

A nondestructive procedure that consists of decompression of the endolymphatic sac from the overlying bone and drainage of its endolymph. This maintains the vestibular neuroepithelium and its innervation.

Decreases endolymphatic pressure and addresses both cochlear and vestibular dysfunctions.

Its role in MD is controversial, with studies that show 90% resolution of vertigo,​​​ and others that demonstrate that it is no more effective than placebo,​​ or that there is insufficient evidence of the beneficial effect of endolymphatic sac surgery in MD.[7][84][85][86][87][88][89]​ A 2023 systematic literature search and meta-analysis revealed a paucity of studies on this surgical procedure, indicating ELS may be a beneficial treatment for patients with MD.[89]​ However, further studies are needed to attain a better understanding of the efficacy of ELS for treating MD.

Endolymphatic sac surgery carries a risk of hearing loss in up to 2% of patients.[93] Other potential complications of this procedure include bleeding from the sigmoid sinus and cerebrospinal fluid leak.

1st line – vestibular nerve section

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ONGOING
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failure of medical and intratympanic therapies; hearing adequate
1st line – 

vestibular nerve section

In this procedure, the vestibular portion of the eighth cranial nerve (CN VIII) is selectively cut and its cochlear portion is left intact; thus, this is potentially a hearing conservation approach. This prevents the vestibular afferent stimuli from reaching the brain.

This does not alter the pathophysiology of MD, but provides relief from vertigo, its most disturbing symptom. It should be avoided in bilateral MD, otherwise oscillopsia (perception of bouncing of the visual field with walking) and permanent imbalance may occur.

Central compensation after vestibular nerve section is crucial for postoperative recovery of balance. Central nervous system disease such as cerebellar dysfunction, multiple sclerosis, physiologic aging, and poor medical condition are relative contraindications for vestibular nerve section.

Vertigo control rates are up to 90% with vestibular nerve section.[94][95] Persistent or recurrent vertigo after vestibular nerve section can be treated by intratympanic gentamicin.

Potential complications are uncommon and include hearing loss, facial nerve paralysis, cerebrospinal fluid leak, and headache.[94]

failure of medical and intratympanic therapies; hearing severely impaired

1st line – labyrinthectomy

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ONGOING
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failure of medical and intratympanic therapies; hearing severely impaired
1st line – 

labyrinthectomy

Involves surgical removal of the inner ear's neuroepithelium in an attempt to eliminate vertigo.

Hearing loss is inevitable with this procedure and it should only be used in patients with no serviceable hearing. Avoided in patients with bilateral disease, as bilateral loss of vestibular input to the brain may result in oscillopsia (perception of bouncing of the visual field with walking) and permanent imbalance.

Central compensation after labyrinthectomy is important for balance recovery, and vestibular rehabilitation therapy after surgery may help speed the recovery. Central nervous system disease, advanced age, and a variety of significant medical conditions can prevent central compensation after surgery and these patients are, therefore, not good candidates for labyrinthectomy.

Vertigo control rates up to 97% after have been reported.[96]

Complications from labyrinthectomy include facial nerve injury (2%) and cerebrospinal fluid leak in 3%.[97]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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