Ménière disease

01OverviewDefinition, clinical context and the essential points that orientate the chapter.

Ménière disease is a clinical syndrome of recurrent vertigo with cochlear symptoms, often initially affecting one ear. Aural fullness, fluctuating hearing and tinnitus may precede or accompany attacks. Between attacks the examination can be normal, and patients may have long remissions. The diagnosis therefore depends on a coherent history over time and objective hearing assessment, not on finding a single characteristic bedside sign during one consultation.

The definite diagnostic pattern includes two or more spontaneous attacks lasting twenty minutes to twelve hours, documented low- to medium-frequency sensorineural hearing loss in the affected ear, fluctuating aural symptoms and no better explanation. Probable disease can have a broader attack duration, up to twenty-four hours, and less complete diagnostic evidence. Clinical uncertainty should be recorded while the pattern evolves. Calling any recurrent dizziness with tinnitus Ménière disease risks missing vestibular migraine, asymmetric hearing pathology or unrelated cardiovascular symptoms.

Key points

Think of recurrent spontaneous vertigo with fluctuating unilateral auditory symptoms.
Definite disease requires at least two attacks lasting twenty minutes to twelve hours.
Document sensorineural hearing loss with audiometry rather than symptom description alone.
Consider vestibular migraine and other explanations before confirming the diagnosis.
Use short symptomatic treatment during attacks and a separate preventive plan.
Betahistine is licensed for Ménière symptoms, but benefit should be reviewed critically.
Address hearing, tinnitus, chronic imbalance and the risks of unpredictable attacks.

02AetiologyUnderlying causes, associations and risk factors, with why each one matters.

Multifactorial inner-ear disorder

The initiating cause is often uncertain. Genetic susceptibility, immune mechanisms and environmental factors have been investigated, but no single explanation accounts for every case.

Unilateral and bilateral disease

Symptoms commonly begin in one ear and may later involve the other. This possibility matters when considering treatments that deliberately reduce vestibular function.

03PathophysiologyThe causal sequence from the underlying abnormality to symptoms and harm.

1
Endolymphatic hydrops
Expansion of the endolymphatic compartment is associated with Ménière disease, but the relationship between hydrops, symptom generation and progression is more complex than simple pressure accumulation.
2
Episodic vestibular disturbance
Intermittent changes in inner-ear function can create a sudden imbalance of vestibular signalling, producing spontaneous vertigo and marked autonomic symptoms during an attack.
3
Cochlear dysfunction
Fluctuating cochlear function can alter hearing thresholds and sound perception. Repeated or progressive injury may leave persistent hearing loss even when vertigo becomes less frequent.

04Clinical features and red flagsSymptoms, examination findings, patterns of presentation and time-critical warnings.

Spontaneous episodic vertigo

Attacks arise without a specific positional trigger and usually interrupt ordinary activity for a substantial period. Ask for the duration of actual spinning rather than the total day of fatigue or nausea. Brief seconds-long bed-turning attacks suggest a different mechanism.

Fluctuating cochlear symptoms

The person may notice muffled hearing, altered sound quality, roaring tinnitus or pressure in the same ear around attacks. Later hearing loss may become more persistent. Bilateral symptoms are possible, so assess each ear separately and avoid assuming the previously affected side remains the only problem.

Between-attack findings

Normal otoscopy and a relatively normal neurological examination between episodes are common. Balance may remain impaired after an attack. Neither a normal clinic examination nor a single near-normal audiogram rules out an evolving episodic disorder.

Migraine overlap

Ask about migrainous headache, photophobia, phonophobia, aura and motion sensitivity. Vestibular migraine is an important competing or coexisting diagnosis. A migraine history does not automatically explain asymmetric sensorineural hearing loss, which still needs investigation.

Unpredictable falls

Some patients describe sudden falls without loss of consciousness, sometimes called vestibular drop attacks. Clarify whether there was syncope, seizure activity or a mechanical trip, assess injury and arrange specialist review. Do not attribute a new collapse to Ménière disease without assessment.

Red flags requiring action

New facial weakness, double vision, dysarthria or limb incoordination during vertigo demands emergency neurological assessment.
Sudden unexplained hearing loss or injurious drop attacks needs prompt specialist review and a practical safety plan.

05InvestigationsWhat to request, why it matters and how to interpret it.

Investigation order

Read from the initial assessment onwards. Tests may run in parallel in urgent care; first-line, preferred, confirmatory, definitive and gold-standard labels appear only when the chapter explicitly states them.

01
Audiometry and comprehensive hearing historyFirst step
Why
Document the auditory component and establish a baseline for follow-up.
Interpretation and limitations
Pure-tone audiometry may show low- or medium-frequency sensorineural loss, especially early in disease. Repeat assessment can demonstrate fluctuation. Audiological findings should be interpreted with symptoms, communication needs and previous records rather than used as an isolated diagnostic signature.
02
Otoscopy and neurological examination
Why
Look for external-ear, middle-ear or central explanations of the presentation.
Interpretation and limitations
Check the tympanic membrane, cranial nerves, eye movements and gait. During a new acute sustained syndrome, central warning signs change the pathway immediately. Middle-ear effusion or wax may explain a conductive component but not necessarily all symptoms.
03
MRI of the internal auditory meati when indicated
Why
Exclude a retrocochlear or cerebellopontine-angle explanation for asymmetric findings.
Interpretation and limitations
Use NICE NG98 criteria and specialist assessment. Localising signs with hearing loss support offering MRI irrespective of thresholds; without localising signs, consider MRI for sensorineural asymmetry of at least 15 dB at two adjacent specified test frequencies.
04
Attack diary and selective vestibular assessment
Why
Clarify the temporal pattern and quantify disability before changing treatment.
Interpretation and limitations
Record attack duration, auditory changes, medication use and functional consequences. Specialist vestibular tests can assess residual function or inform invasive treatment but are not a universal confirmatory test for Ménière disease.

06Differential diagnosisRealistic alternatives and the features that help distinguish them.

Vestibular migraine

Migraine-related vertigo can overlap in duration and sensory symptoms. Recurrent migraine features and the absence of a convincing auditory pattern may favour that explanation.

Vestibular schwannoma

A retrocochlear lesion can cause unilateral hearing loss, tinnitus and imbalance. Progressive asymmetry or localising cranial nerve findings supports targeted MRI assessment.

Positional vertigo

BPPV produces brief attacks initiated by specific positions, with canal-specific nystagmus, rather than the prolonged spontaneous attacks used in definite Ménière diagnostic criteria.

07ManagementImmediate care, first-line treatment, alternatives and escalation.

01DiagnosisConfirm the episodic syndromeFirst stepRecurrent spontaneous vertigo is accompanied by fluctuating hearing, tinnitus or aural pressure.

1Arrange ENT or audiovestibular assessment with audiometry, describing duration, laterality and the relationship between vestibular and auditory symptoms.
2Exclude urgent neurological and sudden-hearing-loss presentations before placing the person on a routine diagnostic pathway.
3AlternativeDiscuss vestibular migraine and alternative causes where the timing or auditory evidence does not fit definite disease.

02AcuteManage a typical established attackA recognised attack occurs without new neurological or auditory warning features.

1Move to a safe place, avoid driving and hazardous tasks, and use the agreed short symptomatic medicine if required.
2Support hydration with small drinks when tolerated and arrange urgent care if vomiting or instability prevents safe management.
3Stop vestibular suppression when the attack settles; continuing interictal treatment should have a separate justified purpose.
4Reassess an attack that is unusually prolonged, different from previous episodes or associated with new focal symptoms.

03OngoingReduce the long-term impactAttacks or continuing hearing and balance symptoms interfere with ordinary life.

1Agree measurable treatment goals using an attack diary and discuss practical changes such as avoiding personally identified triggers and a trial of sensible dietary measures.
2Consider a monitored betahistine trial when appropriate, explaining that licence status does not guarantee benefit and that disease fluctuations complicate interpretation.
3Provide audiology, tinnitus support and rehabilitation for chronic imbalance between attacks rather than relying on one medicine to address every outcome.
4Refer continuing disabling disease for specialist discussion of intratympanic treatment or surgery, including the hearing and balance trade-offs of vestibular-ablative treatment.

Key medicines and prescribing safety2 treatments · regimens, roles and cautions

A licensed option for Ménière symptoms used as a preventive trial rather than a rapid rescue treatment.

Betahistine 16 mg tablets, product 7053

Start 8–16 mg orally three times a day with or after food. The cited product permits a total maintenance dose of 24–48 mg daily in two or three divided doses, with a maximum of 48 mg daily. Agree a review after a therapeutic trial over weeks to months.

Do not use with phaeochromocytoma or hypersensitivity. Monitor asthma and current or previous peptic ulcer disease; use caution with severe hypotension and MAO inhibitors. Antihistamines may oppose its effect. Prefer avoidance during pregnancy under this SmPC; breastfeeding requires individual benefit–risk review; do not extrapolate higher trial doses into this product licence.

Provides temporary relief from attack-related vertigo and nausea when the person's contraindications and safety risks allow.

Prochlorperazine oral tablets for an acute attack

Stemetil 5 mg orally three times daily is the licensed starting regimen for vertigo. Use the shortest attack-related course and stop when symptoms settle; the RCGP toolkit describes short courses up to seven days, with reassessment if symptoms persist. Start lower in older adults.

The product advises avoiding use with hepatic or renal dysfunction, Parkinson disease, hypothyroidism, heart failure, phaeochromocytoma, myasthenia, prostatic hypertrophy, previous narrow-angle glaucoma or agranulocytosis; hypersensitivity is a contraindication. Assess QT and seizure risks, electrolytes and sedating interactions. Drowsiness, postural hypotension and dystonia can worsen balance. Avoid alcohol and driving; pregnancy needs individual review and the product advises interrupting breastfeeding while treated.

08ComplicationsImportant consequences, why they occur and why they matter clinically.

Lasting hearing impairment

Hearing can become less reversible over time, affecting conversation, sound localisation and work. Audiological management should continue even when vertigo frequency decreases.

Chronic disequilibrium

Residual vestibular dysfunction and reduced activity may produce persistent imbalance between attacks, requiring a different treatment strategy from short-term attack suppression.

Injury and participation loss

Unpredictable vertigo or drop attacks can cause falls and restrict travel, employment and recreation. Practical risk reduction should reflect the individual's activities.

09Monitoring and follow-upTreatment response, safety checks and longer-term review.

Track attack frequency, duration and recovery time alongside medicine tolerability; compare several weeks of records rather than a single unusually good or bad day.
Reassess hearing and communication function over time, offering appropriate amplification or other audiological support when needed.
Review persistent unsteadiness separately from episodic vertigo and consider vestibular rehabilitation when a stable deficit remains between attacks.
Discuss work, swimming, heights and driving. In Great Britain, sudden, disabling or recurrent dizziness must be notified to DVLA; Northern Ireland uses DVA, and driving must stop whenever symptoms make it unsafe.

10Special situationsVariants, exceptions and circumstances that change the usual approach.

Interpreting betahistine evidence

The BEMED randomised trial did not demonstrate a difference in vertigo attack rates between placebo and the studied betahistine groups. This supports honest discussion of uncertain preventive benefit and planned review, rather than a promise that treatment protects future hearing.

Procedural trade-offs

Intratympanic steroid treatment and vestibular-ablative approaches have different aims. Gentamicin can reduce troublesome vestibular activity but may worsen hearing and leave imbalance. Choice depends on symptom burden, residual hearing, the opposite ear and informed preferences.

Dietary advice without guarantees

A patient may wish to try reducing salt, caffeine or alcohol, as discussed in NHS information. Frame these as reasonable individual measures and avoid severe restrictive diets or claims of certain disease modification. Maintain hydration and adequate nutrition.

Treating life between attacks

Communication difficulty, tinnitus distress and uncertainty about the next attack can persist during a remission. A plan that records only vertigo frequency may miss the person's largest problem, such as loss of confidence at work or social withdrawal.

11Common pitfallsFrequent interpretation and management errors.

01
Diagnosing definite disease before documenting the auditory component or excluding a more coherent alternative can anchor future care incorrectly.
02
Describing betahistine as a proven hearing-preserving treatment overstates what patients can expect from current clinical evidence.
03
Using regular suppressants for stable interictal imbalance can add sedation without addressing vestibular compensation.
04
Assuming a new collapse or sustained neurological symptom is another Ménière attack may delay assessment of a separate serious condition.