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Michael Strupp

Michael Strupp, MD

FRCP, FANA, FEAN

German Center for Vertigo and Balance Disorders and Department of Neurology

University of Munich, Germany

Topic:Menière’s disease: diagnosis, differential diagnoses, and current prophylactic therapy


Diagnosis and differential diagnoses. The diagnosis is based on the criteria of the Bárány Society . It is important to note that a sensorineural hearing loss in the affected ear by >30dB at each of two contiguous frequencies <2000Hz related to a vertigo episode is required, ideally ± 24h. This can nowadays be measured by the patient using an audioAPP/tablet-based audiogram . This and videoing of nystagmus during an attack greatly improves the specificity of the diagnosis. The major DD are vestibular migraine with an overlap of both diseases (which can be easily pathophysiologically explained), and vestibular paroxysmia (VP); the diagnosis of the latter requires a response to an antiepileptic drug , like lacosamide.


Treatment recommendation. Since MD is most often a chronic remitting disease, an effective and well-tolerated long-term prophylactic treatment is highly needed. However, although various therapeutic approaches have been proposed, there is so far insufficient evidence of the effectiveness of the following measures: low-salt, low-caffeine, low-alcohol diet (Cochrane review (CR)), diuretics (CR ), steroids (no state-of-the art RCT), pulsed low-pressure delivery (RCT ), endolymphatic sac surgery (CR), and betahistine (48-144mg/d (RCT ). Transtympanic gentamycin is effective but impairs vestibular function and may impair hearing; labyrinthectomy/neurectomy are invasive and cause vestibular loss. The latter three should particularly not be applied in bilateral MD, which affects >45% patients in the long-term.


The author’s current recommendation for the treatment of MD is a combination of betahistine (≥96mg tid) and a monoamine-oxidase-B-inhibitor, like selegiline (5mg/d), for >12months.