## Acute vs Prophylactic Management in Meniere Disease Meniere disease management is stratified by phase and severity. The question stem describes an **acute vertigo attack**, not long-term prophylaxis. ### Acute Attack Management **Key Point:** Vestibular suppressants (antihistamines, anticholinergics, benzodiazepines) are first-line for **acute symptomatic relief** during an attack. - **Dimenhydrinate** (or meclizine, cyclizine): H₁ antagonist with anticholinergic properties - Rapid onset; reduces vertigo and nausea within 30–60 minutes - Administered IV/IM during acute attack or oral for mild episodes - Provides immediate symptom control ### Prophylactic (Long-term) Management For **prevention of recurrent attacks** between episodes: | Drug Class | Agent | Mechanism | Use | |---|---|---|---| | **Diuretics** | Hydrochlorothiazide + amiloride | Reduces endolymphatic pressure | First-line prophylaxis; reduces attack frequency | | **Vasodilators** | Betahistine | H₁ agonist; improves microcirculation | Second-line; modest evidence | | **Ablative** | Intratympanic gentamicin | Destroys vestibular hair cells | Refractory cases; high risk of hearing loss | **High-Yield:** The stem explicitly asks for **acute attack** management ("recurrent episodes of vertigo lasting 20 min–2 hrs"). Vestibular suppressants are the **drug of choice for acute symptoms**; diuretics are prophylactic and do not relieve an ongoing attack. **Clinical Pearl:** Patients often confuse acute and prophylactic therapy. Diuretics prevent attacks; vestibular suppressants stop an attack in progress. **Warning:** Intratympanic gentamicin is **not** first-line for acute attacks—it is reserved for refractory, severely disabling disease due to risk of permanent hearing loss and vestibular ablation.
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