Meniere's disease

Ménière's disease is a rare disorder that affects the inner ear. It can cause vertigo, tinnitus, hearing loss, and a feeling of pressure deep inside the ear.

People with Ménière's disease usually experience some or all of these symptoms during sudden attacks, which typically last around two to three hours, although it can take a day or two for the symptoms to disappear completely.

It's worth noting, however, that the symptoms and severity of Ménière's disease vary widely from person to person. Some people may experience frequent attacks of vertigo along with hearing loss, while others may have severe tinnitus with minor vertigo. Other symptoms include sensitivity to sound (hyperacusis) or distorted sound.

See your GP if you experience any of the symptoms of Ménière's disease, so they can try to identify the problem and refer you to a specialist if necessary.

Read more about the symptoms and stages of Ménière's disease and diagnosing Ménière's disease

How Ménière's disease progresses

Ménière's disease often progresses through different stages. In the early stages, most people have sudden and unpredictable attacks of vertigo, accompanied by nausea, vomiting and dizziness.

The attacks of vertigo continue, but may come and go and become less severe. It's common to experience a loss of balance or dizziness before or after these attacks. Permanent hearing loss and tinnitus continue to develop and may be worse during attacks of vertigo.

During the later stages, the episodes of vertigo tend to occur less frequently and sometimes stop altogether over time. However, the tinnitus and hearing loss often become worse and you may be left with permanent balance and hearing problems.

Who is affected

In the UK, it's estimated that around one in 1,000 people have Ménière's disease.

Ménière's disease most commonly affects people aged 20-60 and it's thought to be slightly more common in women than men.

What causes Ménière's disease?

The exact cause of Ménière's disease is unknown, but it's thought to be caused by a problem with pressure deep inside the ear.

Factors that can increase your risk of developing Ménière's disease include a family history of the condition and a chemical imbalance in the fluid in your inner ear.

Read more about the causes of Ménière's disease

How Ménière's disease is treated

Treatments for Ménière’s disease can usually help people with the condition control their symptoms. However, current treatments aren't able to cure the condition.

Possible treatments include:

• medicines to treat the symptoms and prevent attacks
• changes to your eating habits, such as a low-salt diet
• balance training (vestibular rehabilitation)
• relaxation techniques
• surgery, in more severe cases

A number of different surgical procedures may be used to treat Ménières disease, depending on how severe the symptoms are and whether one or both ears are affected. However, the effectiveness of surgery is unclear and research is continuing.

Read more about the treatment of Ménière's disease

Support and advice

Some people with Ménière's disease also find that the condition affects their mental health. The unpredictable nature of the attacks and the restrictions this can place on your activities can lead to feelings of anxiety and depression.

Your GP can offer advice and support if you're finding it difficult to cope with the effect Ménière's disease is having on your life. There are also a number of support groups, that could provide assistance and advice.

Read more about living with Ménière's disease

Information about you

If you have Ménière's disease, your clinical team may pass information about you on to the National Congenital Anomaly and Rare Diseases Registration Service (NCARDRS).

This helps scientists look for better ways to prevent and treat this condition. You can opt out of the register at any time.

Find out more about the register

The symptoms of Ménière's disease vary from person to person. They often begin as sudden attacks, lasting for a few hours. Some people may experience several attacks each week or they may be separated by weeks, months or even years.

See your GP if you experience any of the symptoms of Ménière's disease, so they can try to identify the problem and refer you to a specialist, if necessary.

Main symptoms

The main symptoms of Ménière's disease are:

• vertigo – the sensation that you, or the environment around you, is moving or spinning
• tinnitus – hearing sounds from inside your body, rather than from an outside source
• hearing loss, with a particular difficulty hearing deep or low sounds
• a sense of pressure or fullness deep inside the ear

These symptoms usually only affect one ear at first, but both ears often become affected over time.

Vertigo and tinnitus are described in more detail below.

Vertigo

Vertigo is one of the most common and noticeable symptoms of Ménière's disease. 

As well as a sensation of spinning, you may also experience additional symptoms during an attack of vertigo, such as dizziness, feeling or being sick, and problems with balance. You may have difficulty standing or walking. Occasionally, you may have "drop attacks", where you suddenly fall to the ground.

During a severe attack, you may also experience sweating, diarrhoea and rapid or irregular heartbeats.

Tinnitus

Tinnitus is usually more noticeable when you're tired or when it's quiet, as there's less background noise to distract you from sounds coming from inside your body.

Examples of sounds you may hear include buzzing, humming, grinding, hissing and whistling.

Stages of Ménière's disease

Ménière's disease is often divided into early, middle and late stages.

However, the progression of Ménière's disease varies between individuals. You may not necessarily pass through each of these stages and the severity of the symptoms may also vary. In general, people experience more attacks during the first few years, and then as the attacks decrease in frequency over time, the hearing loss becomes progressively worse.

Some or all of the following symptoms may be experienced before an attack:

• loss of balance 
• dizziness and lightheadedness
• headache and increased ear pressure
• increased hearing loss or tinnitus
• sensitivity to sound
• a feeling of uneasiness

If a person is aware of these warning symptoms, it can allow them to move to a safer or more comfortable situation before an attack.

The stages of Ménière's disease are described in more detail below.

Early stage

The early stage of Ménière's disease consists of sudden and unpredictable attacks of vertigo. These are usually accompanied by nausea, vomiting and dizziness. You may lose some hearing during the attack, and you may experience tinnitus at the same time. Your ear may also feel blocked and uncomfortable, with a sense of fullness. Some people may also experience sensitivity to sound.

Attacks of vertigo at this stage can last from 20 minutes to 24 hours, but usually last around two to three hours. Your hearing and the full sensation in your ear usually returns to normal between attacks.

Middle stage

The middle stage of Ménière's disease consists of continuing attacks of vertigo, with the attacks becoming less severe for some people. However, tinnitus and hearing loss often become worse.

During the middle stage, you may experience some periods of remission (where your symptoms go away), which can last for up to several months. Some people may still experience symptoms of tinnitus, sensitivity to sound or loss of balance between attacks of vertigo.

Late stage

During the late stage of Ménière's disease, the episodes of vertigo occur far less frequently. There may be months or even several years between attacks or they may stop altogether. However, you may be left with balance problems, and you may be unsteady on your feet, particularly in the dark.

Hearing problems and tinnitus tend to become progressively worse during the late stage of Ménière's disease.

The exact cause of Ménière's disease isn't clear, although it's thought to be caused by a problem with the pressure in the inner ear.

The inner ear is made up of:

• the cochlea – a coiled, spiral tube that contains two fluid-filled chambers and is responsible for hearing
• the vestibular apparatus – a complex set of tubes that help to control balance

The fluid inside the inner ear is called endolymph.

If the pressure of the endolymph fluid changes – for example, because there is too much fluid – it can result in symptoms such as vertigo and tinnitus.

It's thought that this pressure change is responsible for Ménière's disease, although it hasn't been proven.

Increased risk

Although the exact cause of Ménière's disease is unknown, the following factors may increase the risk of developing the condition:

• autoimmunity – when your immune system attacks your own tissues and organs by mistake
• genetic (inherited) factors – for example, if you have a family history of the condition
• a chemical imbalance in the fluid in your inner ear – as a result of too little or too much sodium or potassium in your body
• a problem with the blood vessels – there's a link between Ménière's disease and migraines, which are thought to be caused by the narrowing and widening of blood vessels
• some viral infections – such as meningitis

There's no single test for Ménière's disease, and the condition can be difficult to distinguish from other conditions with similar symptoms.

For example, migraines and ear infections can also affect your balance and hearing. A viral infection of the balance nerve (vestibular neuronitis) or the inner ear (labyrinthitis) can also produce similar vertigo attacks.

Seeing your GP

See your GP if you experience any of the symptoms of Ménière's disease.

They'll ask you to describe your symptoms to find out if a pattern is emerging that could indicate Ménière's disease.

For Ménière's disease to be diagnosed, you'll need to have the following characteristic symptoms:

• vertigo (a feeling that the environment around you is spinning) – at least two episodes of vertigo lasting 20 minutes or more within a single Ménière's disease attack
• hearing loss – tests must confirm that hearing loss is caused by damage to the sensitive hair cells inside the cochlea (the coiled tube in the inner ear)
• tinnitus (hearing noises from within your body) or a feeling of pressure in your ear

Your GP may also carry out a general physical examination to rule out other possible causes of your symptoms. This may involve listening to your heartbeat, checking your blood pressure and examining the inside of your ears.

Seeing a specialist

If necessary, your GP can refer you to a specialist for further tests.

In most cases, you'll probably be referred to an ear nose and throat (ENT) specialist at the ENT department of your local hospital.

You can also be referred to a specialist in audiovestibular medicine for hearing and balance assessment, although this service may not be available in every hospital.

Hearing tests

The specialist will be able to assess the extent of your hearing loss by using hearing tests, such as an audiometry test.

During an audiometry test, you listen to sounds of different volume and pitch produced by a machine and signal when you hear a sound, either by raising your hand or pressing a button.

Read more about how hearing tests are carried out

Videonystagmography

Videonystagmography (VNG) may be used to check for signs of uncontrollable eye movements (nystagmus) because this can indicate a problem with balance.

During this test, special goggles are placed over your eyes and you'll be asked to look at various still and moving targets. The goggles are fitted with a video camera to record your eye movements.

Caloric testing

A caloric test involves putting warm and cool water or air in your ear for about 30 seconds. The change in temperature stimulates the balance organ in the ear, allowing the specialist to check how well it's working.

This test isn't painful, although it's normal to feel dizzy for a few minutes afterwards.

Electrocochleography

Electrocochleography is a test used to measure how your hearing nerves respond to sound.

During this test, a series of electrodes are attached to your head and a thin probe or needle is passed into your ear so it touches or passes through your eardrum. Local anaesthetic will be used to numb your eardrum before the procedure if a needle is going to be passed through it.

You will then listen to a series of loud clicks, while the activity of your nerves is picked up by the electrodes and probe or needle.

Scans

In some cases, a magnetic resonance imaging (MRI) scan of your head may be carried out to look for any abnormalities in your brain – such as an acoustic neuroma (a non-cancerous tumour) – that could be causing your symptoms.

Treatment can usually help to control the symptoms of Ménière's disease, although there's currently no cure.

Your ear, nose and throat (ENT) specialist and your GP can help you manage your symptoms. Possible treatments include:

• dietary advice – particularly a low-salt diet
• medication to treat and prevent attacks
• treatment for tinnitus 
• treatment for hearing loss
• treatment called vestibular rehabilitation to cope with balance problems
• treatment for stress, anxiety and depression
• surgery

Your GP and ENT specialist should provide you with advice tailored to your individual needs, and should develop a plan to help you manage your symptoms.

In some cases, the treatment available may depend on what your local NHS Clinical Commissioning Group (CCG) can provide.

Treatment during an attack

During an attack of Ménière's disease, you may be prescribed medication to treat the symptoms of vertigo, nausea and vomiting.

This is usually prochlorperazine or an antihistamine. If these work, you may be given a supply to keep, so you can take them quickly during an attack.

Prochlorperazine

Prochlorperazine can cause side effects including tremors (shaking) and involuntary body or facial movements. It can also make some people feel sleepy.

Check the patient information leaflet that comes with your medicine for the full list of possible side effects, or read more about prochlorperazine.

If you experience vomiting during your attacks, you can take a type of prochlorperazine called Buccastem. This comes as a tablet that you place between your gums and your cheek, on the inside of your mouth. The tablet dissolves and is absorbed into your body.

Antihistamines

Antihistamines you may be prescribed include cinnarizine, cyclizine and promethazine teoclate.

Antihistamines can make you feel sleepy. Headaches and an upset stomach are also possible side effects. Check the patient information leaflet that comes with your medicine for the full list of possible side effects.

What to do during an attack

During an attack, take your medication as soon as possible and grab the nearest available support. Get into a position in which you feel most stable or comfortable, and keep as still as possible. If you need to move, do so slowly and carefully. Close your eyes or keep them fixed on objects in front of you, and don't turn your head quickly.

Once your symptoms start to improve, it's best to gradually try to move around, as this encourages your brain to use your vision and other senses to compensate for the problems in your inner ear.

Severe attacks

If you suffer severe vertigo, dizziness, nausea and vomiting during an attack of Ménière's disease, you may need to be injected with prochlorperazine by your doctor.

If you suffer severe vertigo with or without nausea during an attack, your doctor may also prescribe you a tablet of Buccastem that dissolves very quickly in your mouth (see above).

In particularly severe cases, you may need to be admitted to hospital to receive intravenous fluids (through a vein) to keep you hydrated.

Preventing attacks

Your GP can prescribe a medication called betahistine to help reduce the frequency and severity of attacks of Ménière's disease, or you may be advised to change your diet.

Special diets

Although it has not been proven to be consistently effective, following a diet without added salt can help some people to control their symptoms. It's possible that this type of diet might alter the fluids in your inner ear.

Avoiding excessive caffeine, found in drinks such as tea and coffee, is also usually recommended.

Betahistine

Betahistine is thought to reduce the pressure of the fluid in your inner ear, relieving the symptoms of Ménière's disease. Your GP may recommend trying them to see if they help.

Betahistines are usually available as tablets to be taken three times a day. Your GP will discuss how long you need to take them for, which could be a few weeks, or up to a year. Possible side effects include a headache, upset stomach and a rash.

Treating tinnitus

A number of different treatments can be used to treat tinnitus caused by Ménière's disease. Some possibilities include:

• Sound therapy – the effects of tinnitus are often more pronounced in quiet environments. The aim of sound therapy is to fill the silence with neutral, often repetitive sounds to distract you from the sound of tinnitus.
• Relaxation techniques – tinnitus can be a distressing and intrusive condition. Relaxing by practising yoga or special breathing techniques may help you to avoid stress and anxiety.
• Cognitive behavioural therapy (CBT) – this is a therapy based on the knowledge that Ménière's symptoms can have a significant psychological effect, resulting in negative thoughts and changes in behaviour. This may aggravate your symptoms and create a vicious circle. CBT is given by a specially trained professional who aims to change the way you think and behave, to break this cycle.

Read more about treating tinnitus

Treating hearing loss

You may experience permanent hearing loss if Ménière's disease is in the middle or end stages. Ménière's disease tends to make you more sensitive to loud sounds, and also makes it more difficult for you to distinguish low-pitched sounds.

There are a variety of hearing aids available. Hearing therapists and organisations, such as Action on Hearing Loss, can provide you with helpful advice for dealing with hearing loss.

Read more about treating hearing loss

Vestibular rehabilitation

Vestibular rehabilitation (VRT) is usually provided by a hearing specialist or physiotherapist. Your GP may be able to refer you for VRT, although it will depend on the availability in your area.

A vestibular therapist or specially trained physiotherapist can help improve your balance by teaching you vestibular rehabilitation techniques. These exercises teach you how to cope with the disorientating signals coming from your inner ear. You're taught to use alternative signals from your eyes, ankles, legs and neck, to keep you balanced.

Vestibular therapy is usually used in the middle or late stages of Ménière's disease, after the severe attacks of vertigo have stopped, but when balance problems may remain.

In some cases, it may be possible to use VRT without specialist help. Research has shown that some people can improve their symptoms by using self-help VRT booklets. However, you should discuss this with your doctor first. 

Surgery

In severe cases, surgery can be performed to control the attacks of vertigo. However, surgical procedures are usually only used if other treatments have failed.

The type of surgery you have will depend on your symptoms, and whether both ears are affected. You could have:

• non-destructive surgery
• selectively destructive surgery
• destructive surgery

Non-destructive surgery

Non-destructive surgery may be used if your hearing in the affected ear is "socially adequate" (you can hear sounds that are below 50 decibels). This type of surgery aims to change the progression of Ménière's disease by reducing the severity and frequency of your symptoms.

Types of non-destructive surgery include:

• endolymphatic sac decompression – this can help to reduce the pressure in your inner ear by increasing the drainage of the fluid of your inner ear
• injecting steroid medication through the eardrum

The National Institute for Health and Care Excellence (NICE) has more information on micropressure therapy for Ménière's disease.

Selectively destructive surgery

In selectively destructive surgery, the balance part of the inner ear is destroyed with a medicine called gentamicin. This is injected through the ear drum (the thin layer of tissue separating the outer ear from the middle ear) and enters the labyrinth (the system of tubes in the inner ear).

Gentamicin should mainly damage the balance part of your ear, but there's a risk it could damage your hearing as well.

Some surgeons prefer to apply the gentamicin directly to the inner ear during a minor operation. This means they can control the exact dose of gentamicin that enters your ear.

Destructive surgery

Destructive surgery may be considered if only one ear is affected by Ménière's disease. The hearing in the affected ear must be considered to be "socially inadequate" (you can't hear enough to function in social situations). As an approximate guide, if you can't hear sounds below 50 decibels, this may count as socially inadequate.

Destructive surgery is used to destroy the part of your inner ear causing your vertigo attacks. However, these operations can cause permanent hearing loss in the treated ear, so will only be considered if you already have permanently reduced hearing in the affected ear.

Destructive surgery can be done by:

• destroying the balance part of your audio-vestibular nerve – the nerve transmitting sounds and balance information to the brain
• destroying part of your vestibular labyrinth (labyrinthectomy) – the system of tiny, fluid-filled channels in the ear

After surgery, your other ear will take over your hearing and balance functions.

Safety and effectiveness of surgery

There are very few clinical trials looking into the effectiveness of surgery for Ménière's disease, which is why surgery is rarely considered. If your ENT specialist thinks you may benefit from having surgery, they'll discuss the procedure and any risks in more detail with you.

Support groups and charities

There are several support groups and charities that can provide you with useful information and advice about living with Ménière's disease. They can also put you in touch with other people with the condition.

See living with Ménière's disease for more information

Ménière's disease and the placebo effect

The placebo effect is the unusual psychological effect that can occur when a person is given a "dummy" medication, such as a sugar pill. They feel better after taking the pill, because they think they're being given real medication.

Although there's limited scientific evidence to suggest that many of the self-help measures and treatments used for Ménière's disease are consistently effective, they can help some people to control their symptoms because of the placebo effect.

Living with Ménière's disease can be difficult and frustrating. Your balance and hearing may be significantly impaired during an attack, meaning that certain activities can be dangerous.

The unpredictable nature of the condition means you may need to change your daily activities so you don't place yourself, or others, in danger. Situations you may need to avoid include:

• swimming
• climbing ladders or scaffolding
• operating heavy machinery
• driving (see below)

You may also need to make sure that someone is with you most of the time, in case you need help during an attack.

These restrictions may leave you feeling stressed, anxious, or depressed. Speak to your GP if you're finding it difficult to come to terms with the effect that Ménière's disease is having on your life. They can offer advice and support.

Support groups and charities

There are also several support groups and charities that provide useful information and advice about living with Ménière's disease. They can put you in touch with other people who have the condition, so you can share experiences and provide support to one another.

As the symptoms of Ménière's disease can affect your work and family life, you may need advice on financial and relationship issues. The Citizens Advice Bureau and GOV.UK may be useful.

If you're caring for someone with Ménière's disease, you can find relevant information, advice and help by visiting Care Information Scotland.

Driving

If you experience sudden episodes of vertigo and dizziness, you must inform the Driver and Vehicle Licensing Agency (DVLA) about your condition before driving.

You'll need to fill in a form about your condition and the DVLA will ask for permission to obtain reports on your condition from your doctor or specialist.

Your case will be assessed on an individual basis, but it's likely that you won't be allowed to continue driving if you experience sudden attacks of vertigo and dizziness without any warning signs.

Driving won't be permitted again until you have control of your symptoms, in which case you'll need to reapply for a licence. Your GP or ear, nose and throat (ENT) specialist will have to confirm your symptoms have improved and are under control.

If you drive a heavy goods vehicle or a passenger-carrying vehicle and you're diagnosed with Ménière's disease, you usually have to be symptom-free for a year before you can reapply for a licence.

Visit GOV.UK for more information about driving with a disability or health condition