A Shotgun Approach to Treatment
As we have reviewed Meniere’s disease treatments over the last several weeks, it is clear that there is not consensus on the proper, most effective treatment. There is also no consensus on the cause of Meniere’s type symptoms. Various theories on etiology include:
- Overproduction of endolymph by the stria vascularis
- Blockage of the endolymphatic duct
- Blockage of the reuniting duct
- Rupture of Reissner’s membrane
- Auto-immune disorder
- Migraine variant
The first four on this list all involve hydrops (too much fluid), and techniques to attempt regulating fluid have been discussed. We have also discussed the overlap between Meniere’s and migraine. Dr. Carol Foster, at the University of Colorado has proposed a combined approach, where they treat early, suspected Meniere’s disease as a possible hydropic condition AND/OR a cerebro-vascular condition such as migraine. Similar to the treatment ladder proposed for hydrops, they have a step wise approach to migraine, beginning with avoidance of migraine triggers, and moving to prophylactic medications if symptoms persist or progress. Here is her description of these steps, which can take place simultaneously with conventional hydrops treatments:
Migraine trigger elimination
Common migraine food triggers include monosodium glutamate, chocolate, red wine, fermented dairy products including yogurt, and aged or pickled foods. Trigger elimination is advocated as treatment for migraine-associated vestibular disorders, but controlled studies demonstrating the efficacy of this treatment in Ménière’s disease are lacking.
The migraine group recommends avoidance of these foods with the belief that Ménière’s disease will fluctuate and worsen if migraines are uncontrolled. There is no expectation that these triggers modify hydrops, but they are often included in dietary regimens for hydrops control based on their empiric efficacy. Our protocol is to recommend avoidance of these food triggers in patients with migraine headaches, aura, or in Ménière’s patients under the age of 50 years because migraine is the most common vascular risk factor in that group.
Migraine prophylactic medications
Amitriptyline, beta blockers, calcium channel blockers, acetazolamide, and topiramate are commonly used in the prevention of migraine headaches and are also used for vestibular symptoms in migraineurs. Migraine prophylactic medications are used by some centers for Ménière’s disease but controlled studies are lacking.
Migraine and hydrops have not been shown to be causally related, so migraine prophylactic medications are generally used only by the migraine group with the belief that vasospasm and other migraine phenomena can be controlled by these drugs. Calcium channel blockers such as verapamil, and in Europe, flunarizine, are effective in migraineurs. The carbonic anhydrase inhibitors have some diuretic effects and so may impact hydrops directly in addition to treating migraine. The blockers are also used in the treatment of hypertension and so may be of use in Ménière’s patients who also have migraine and hypertension.”
Dr. Foster’s article makes it clear that this approach is largely theoretical and lacks controlled studies of efficacy. As I mentioned in a previous blog on Meniere’s/Migraine overlap, Ghavani and colleagues at the University of Califonia/Irvine have followed up with patient diagnosed with Meniere’s, yet treated as migraine, with impressive results. This is an area that deserves study, but it will be some time before any conclusions can be drawn.