Medical Treatments for Meniere's Disease

Since the attacks of Meniere’s disease occur irregularly, may be triggered by outside forces, and may go into short or long remissions, it is often extremely hard to determine if any given treatment is actually working or if the disorder is just in a quiet phase. This has made studying this disease extremely difficult, often producing scientific opinions that contradict one another.

There are many different treatments available for Meniere’s disease. Some will work better than others will for individual patients. It is often very hard to find a treatment that will work best for any given person. This usually requires much trial and error. Since there is no known cure, treatments are usually divided into those that minimize symptoms, those that prevent attacks, those that stop attacks, and those that destroy one part of the inner ear system to eliminate some symptoms. Many of the treatments do not seem to affect how the disease progresses, so that there may be some progressive hearing loss, even if the vertigo attacks are controlled. Some of the surgical treatments may destroy part of the inner ear, the balance mechanism, to prevent the vertigo attacks, but there may still be the tinnitus, hearing loss, or fullness symptoms. A good medical review of these treatments was written by Slattery and Fayad (see reference/bibliography page).

For the symptom of vertigo, most doctors start with one or more of a group of medications known as vestibular suppressants. These are the same groups of medications that are used to treat vertigo caused by other causes, such as acute labyrinthitis or motion sickness, and to treat nausea and vomiting caused by other disorders. Commonly used medications include the following.

Benzodiazepine tranquilizers such as Diazepam(Valium®)work by inhibiting the nerve cells that carry balance information to the brain; they tend to minimize vertigo as well as calm the anxiety that may be associated with an attack of Meniere’s. These types of medications tend to be habit forming, may cause excessive daytime sedation, and may even lead to disequilibrium if too much is ingested. Lorazepam (Ativan®) is a similar medication that may be used for "inner ear sedation." Since these drugs are absorbed quickly and work within 1 to 2 hours, some doctors use them only as needed to help control vertigo attacks. Others feel that they should be given regularly (which may be a practical idea for acute labyrinthitis, which usually lasts for days to weeks, but may not be advisable for Meniere’s, because this disorder may occur irregularly for years).

Some antihistamines are very effective in suppressing the vestibular apparatus and minimizing vertigo. The common ones include the seasickness pills meclizine (Antivert®, Bonine®) and dimenhydrinate (Dramamine®), the allergy medication diphenhydramine (Benadryl®), and the antiemetic promethazine (Phenergan®). They may be taken on a regular basis, when the person feels that there is a chance that an attack may be beginning (such as just prior to a woman's menstrual period), or only when actually needed for vertigo spells. Most of these antihistamines have various degrees of side effects, especially dry mouth and sedation (drowsiness). They should be avoided when operating machinery or driving.

Anticholinergic medications work by blocking a neurotransmitter, acetylcholine, that works in the synapses between nerve cells. They particularly suppress the activity of nerve cells in the vestibular nucleus, cutting down on their response to stimulus from the vestibular system (Derebery MJ. The diagnosis and treatment of dizziness. Med Clin North Am. 1999; 83:163-177); this helps prevent the dizziness associated with motion sickness as well as the vertigo of Meniere’s disease. Commonly used medications include atropine(Donnatal® ), scopolamine(Transderm Scop® ), and glycopyrrolate (ROBINUL ® ), as well as other medications that are used less often.

Atropine and glycopyrrolate (ROBINUL ® ) are given in pill form, whereas scopolamine is most commonly used as a transdermal skin patch that can be applied for 3 days. It is often used to prevent seasickness. A patch takes 4 hours to become effective, so it is not advisable to use a patch for a sudden attack of vertigo. It may be helpful in preventing vertigo if applied hours before a trigger is likely to cause an attack. If it is used for too long (days to weeks in a row, taking it off may cause motion sickness-like symptoms, as the body gets used to the absence of the medication. Atropine must be taken often, as a 0.4 - 0.6 mg tablet (which can be placed under the tongue to dissolve rapidly) every 4 to 6 hours. It has strong effects on the brain, and causes dry mouth and blurry vision. Glycopyrrolate (ROBINUL® ) is usually taken as a 1 - 2 mg tablet twice a day. Its helpful effects last around 7 hours. Like atropine, it may also cause dry mouth and constipation, but blurry vision is less common. All of the anticholinergics may cause a series of side effects known as the anticholinergic syndrome. Patients may have flushing, decreased sweating and urination, blurred vision, and confusion or lethargy if too much is taken.

Glycopyrrolate (ROBINUL®) is a medication that is used for stomach ulcers as well as in anesthesia. However, it has been found to suppress inner ear vertigo symptoms and may be combined with other medications for even more effect in difficult cases of Meniere’s. Some physicians (Slattery WH III, Fayed JN. Medical treatment of Meniere’s disease. Otolaryngol Clin North Am. 1997; 30:1027-1037) have suggested combining it with diazepam, whereas others have suggested using it with a vasodilator (a drug that increases the flow of blood to parts of the body; in this case, to the inner ear and brain) to help bring on remissions of Meniere’s disease. Dr. Ian Storper and colleagues (Storper IS, Spitzer JB, Scanlan M, Use of glycopyrrolate in the treatment of Meniere’s disease, Laryngoscope, October 1998; 108, 1442-1445) have shown significant reduction in vertigo symptoms (and perhaps a tendency to decreased tinnitus also with the use of glycopyrrolate). Their recommended dosage is 2 mg twice a day as needed at the onset of attacks. Since glycopyrrolate has a rapid onset of action, it can be used to abort an attack of Meniere’s vertigo, particularly if it is taken immediately, as soon as one notices the symptoms and, before the attack has reached full intensity. They found that patients reported a relative lack of sedation (compared to antihistamines or benzodiazepines) paired with a long duration of action. Some patients did experience dryness of the mouth. Since this medication should not be used in patients with certain other medical conditions (such as glaucoma, myasthenia gravis, and gastrointestinal or urinary tract obstruction). It is only available by prescription.

Another approach uses a combination therapy, in which regular doses of glycopyrrolate (ROBINUL®) are taken along with a vasodilator. It is felt that the vasodilators may help prevent vertigo symptoms, especially when combined with a low-salt diet (see below). Some of the vasodilators used are high doses of niacin (vitamin B3 or nicotinic acid, the same vitamin that may be used to help lower cholesterol), papaverine (Pavabid®), some of the calcium channel blockers (nimodipine, verapamil), or even ACE inhibitor drugs.

Another medication that is used in Europe but is not yet available in the U.S., is betahistine (Serc®). This chemical is similar to histamine, which had been used in the past for treatment of Meniere’s disease. It is felt that it works as a vasodilator, increasing the flow of blood to the inner ear, somehow cutting down on vertigo symptoms. It may also work to prevent Meniere’s attacks.

One unusual medicine that is available is the homeopathic substance Vertigoheel®. This is an unusual combination of two herbal extracts, ambergris, and mineral oil that work to suppress vertigo by an unknown mechanism. Although a homeopathic drug, it is listed in the standard Physicians Desk Reference® (PDR) and can be dispensed like any other prescription medication: normally, one doses it three times a day and should check to see how well it is working after 10 days.

Since autoimmune inner ear disorders may be very hard to diagnose and may produce symptoms very similar to Meniere’s disease, some doctors recommend a trial of treatment with corticosteroids (such as prednisone or dexamethasone). The corticosteroids (not the "performance enhancing" steroids illegally used by athletes) used may suppress autoimmune disease and control inflammation throughout the body. As they have significant long-term and short-term side effects, steroids need to be used with caution under close physicians supervision. Some doctors inject or instill dexamethasone into the inner ear through the eardrum (transtympanic instillation) to limit the effects of the steroid just to the affected ear.

Other medications may be used less commonly, depending on the individual experience of the treating doctor. Some of these include antiemetics used for cancer or surgery such as metoclopramide (Reglan®), ondansetron (Zofran®), and granisetron (Kytril®), the anti-epilepsy medication phenytoin (Dilantin®), calcium channel blockers (nimodipine, verapamil), or even herbal medications (ginko biloba).

Finally, when the vertigo symptoms of Meniere’s disease are so bad that nothing else helps, some doctors will treat with medications (or even surgery) to destroy part of the inner ear, preventing the abnormal vestibular system from sending its disordered information to the brain, where it is perceived as vertigo. This can be done by giving gentamicin or streptomycin, two of the ototoxic antibiotics, either throughout the body or by direct injection into the inner ear, to poison and destroy the vestibular system (without damaging hearing that much). This is known as a chemical labyrinthectomy and should be only used when the vertigo is extremely severe and some hearing loss is acceptable.

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