Ménière's disease:
understanding and treating attacks of vertigo

1. What is Ménière's disease?

Ménière's disease is a condition of the inner ear that shows itself in recurring attacks — not as a permanent state. Between attacks, many people feel completely normal; by the time they are sitting in the practice, most are free of symptoms.^¹

At its core is a malfunction of the membranous labyrinth — the fluid-filled system of canals in the inner ear that is responsible for both hearing and balance. Because both senses share the same fluid, the symptoms occur together: everything spins, and the affected ear hears less well — the decisive distinguishing feature. The condition usually starts on one side.

2. The classic triad

Ménière's disease is defined by three symptoms. Only when they occur together does the picture fit.^¹,²

• 1. Attacks of spinning vertigo: 20 minutes to several hours, often with severe nausea and vomiting. Episodes lasting seconds or several days argue against Ménière's.
• 2. One-sided hearing loss that fluctuates at first: the point most often overlooked. Early on, hearing between attacks is often normal again, and the low tones are affected first. Only later does the hearing loss become permanent.
• 3. Ringing in the ear and a feeling of pressure: a low-pitched roaring in the affected ear (see Ringing in the ears) with a sense of fullness. Many people feel the pressure as a warning sign — a window in which to take on-demand medication and find a safe place.

An attack often announces itself through increasing pressure in the ear, then the spinning vertigo sets in with full force; afterwards, exhaustion often lingers for one to two days. Loss of consciousness is not part of the picture.

3. Which kind of vertigo is it?

Telling the causes apart usually comes down to two questions: How long does an episode last — and what triggers it?

Important: migraine-associated vertigo is more common than many people think — and is often misread as Ménière's. If you have migraine, mention it: the treatment is fundamentally different.

4. Causes: endolymphatic hydrops

The prevailing explanatory model is called endolymphatic hydrops: endolymph builds up in the membranous labyrinth. The pressure stretches the fine membranes; if they become leaky, endolymph and perilymph mix, and the shift in ions throws the sensory cells out of rhythm.^¹,³

As plausible as that sounds, it is a model, not a proven chain of cause and effect. Endolymphatic hydrops can also be detected without any Ménière's symptoms, and why the fluid builds up remains unclear — impaired reabsorption, anatomical peculiarities, autoimmune processes and genetics are all being discussed.

• Clustering in families — some of those affected have further cases in the family.
• A history of migraine — strikingly common, which makes telling the conditions apart harder.
• Salt, caffeine, alcohol, stress — are seen by many as triggers. This has not been proven; it may hold true for an individual, which is why a diary is worth more than any list of things to avoid.

5. Diagnosis based on the course

There is no test that proves Ménière's disease. The diagnosis is clinical: a description of the attacks, documented hearing loss, and ruling out other causes.^⁴ It takes time, because the pattern only shows itself over several episodes.

• History: How long do the attacks last? Are there warning signs? Do you hear less well during them?
• Ear microscopy: to rule out earwax and inflammation.
• Pure-tone audiogram — repeatedly: the most important objective building block. What is looked for is a low-frequency hearing loss that changes over time.
• Balance testing: semicircular canal function and nystagmus.
• MRI: not to confirm the diagnosis but to rule things out — such as a vestibular schwannoma.
• Attack diary: date, duration, warning signs, hearing, medicines.

It is this last point in particular that often decides how quickly the diagnosis is made: once written down, durations and intervals form a pattern — more in the guide Prepare for a doctor's appointment.

6. Treatment during an attack

During an attack, the vertigo can hardly be cut short. The realistic goal is to make the accompanying symptoms bearable and to avoid injuries — that sounds modest, but it makes a big difference.

Having on-demand medication ready to hand takes away much of the condition's terror. Ask specifically what you may take during an attack and how often — the treatment decision always lies with the treating practice.

7. Preventing attacks

This is where the focus of treatment lies — and at the same time where the evidence is thinnest. Expecting a reliably effective prevention brings more disappointment than benefit.

Betahistine: standard in Germany, mixed evidence

In Germany, betahistine is the medicine most often prescribed to prevent attacks. It is thought to improve blood flow in the inner ear and to act on how balance signals are processed; many patients report an improvement, and it is usually well tolerated.

The evidence supports this only in part. A large, carefully blinded study found no difference between betahistine and a placebo; smaller studies and clinical experience point to a benefit. In practice this means that a trial of treatment is justifiable because the side-effect profile is favourable — combined with the question: how will we tell after three to six months whether it is working?^¹,²

A low-salt diet and diuretics

Both follow the same logic: less fluid in the body is meant to lower the pressure in the inner ear. A low-salt diet carries little risk, but robust proof that it works is lacking. Diuretics require checks of blood pressure, kidney values and electrolytes. Plausible as a concept, thin as evidence.

• Look for your individual triggers — a diary kept over eight weeks shows more than any general list.
• Balance training — worthwhile between attacks. It does not prevent attacks, but it improves recovery afterwards.
• Sleep and regularity — irregular sleep is thought to encourage attacks; not proven, but risk-free.
• Treat migraine as well — if migraine is present at the same time, treating it can help reduce the vertigo episodes too.

8. Intratympanic procedures

If attacks remain frequent and severe despite consistent treatment, procedures come into question in which a medicine is injected through the eardrum and passes from there into the inner ear — a few minutes under local anaesthetic.

Hearing aids over time

If the hearing loss becomes permanent, a hearing aid is part of the treatment plan — and is often put off for too long. One poor ear mainly costs you the ability to tell which direction sounds are coming from. Modern hearing aids can also cope with fluctuating hearing.

9. Risk of falls and driving

The most underestimated part of this condition is not the attack but what happens in between: the fear of the next one. If you never know whether you will be lying helpless on the floor within the next hour, at some point you start avoiding travel and restaurants.

This is not oversensitivity but a consequence of genuine unpredictability — yet it can take on a life of its own and turn into avoidance behaviour that restricts you more than the attacks do. If you recognise yourself in this, say so: behavioural therapy works well for accompanying anxiety disorders, and combining ENT treatment with psychotherapeutic support is good care, not a sign of weakness.

Take the risk of falls seriously

• Prepare your home — non-slip mats, grab rails, no loose rugs, a night light.
• No ladders or scaffolding — not even in symptom-free phases, as long as attacks come without warning signs.
• Only swim with someone else — an attack in the water is life-threatening.
• So-called drop attacks — sudden falls without loss of consciousness are rare, but they are a reason to rethink the treatment.

10. Everyday life with Ménière's disease

• Always carry an emergency kit — on-demand medication, water, a bag. Being prepared reduces tension.
• Take warning signs seriously — rising pressure in the ear or ringing that grows louder is your window: sit down, leave the car where it is, postpone the appointment.
• Tell the people around you — colleagues and family should know that during an attack you only need to lie down.
• Adapt your workplace — the risk of falling from height, operating machinery and working alone all need to be discussed; the company doctor (Betriebsarzt) is the right person to talk to about this.
• Keep all your medicines in one place — prevention, on-demand and long-term medication documented together. That cuts short every follow-up question at the practice and the pharmacy.

Finally, a realistic outlook: in many people the attacks become less frequent over the years, while the hearing loss remains — so the course is not a straight line downhill. If troublesome ringing in the ear remains, the article on tinnitus can help; for unsteadiness when walking, take a look at balance disorders.

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