Making the diagnosis

Differential diagnosis

Criterion D made concrete. The duration and the hearing picture do most of the work — and the single hardest call is telling Ménière’s from vestibular migraine, which it also resembles and coexists with.

The vestibular-migraine problem

Trainee

Vestibular migraine is the key contrast: both cause episodic vertigo with nausea, but VM spares the hearingand carries a migraine link, whereas Ménière’s brings documented fluctuating low-frequency loss with tinnitus and fullness.1 The two genuinely overlap and coexist, so re-examine the diagnosis over time.

Ménière’s against its mimics

Ménière’s is held as the reference row; tap a mimic to surface the single feature that most reliably separates it.

ConditionTypical durationHearing
Ménière's diseasereference20 min – 12 hFluctuating → progressive low-frequency SNHL
5 min – 72 hSpared (no progressive loss)
Seconds (< 1 min)Normal
Single attack, daysNormal (spared)
Seconds, provokedLow-frequency air–bone gap (with normal reflexes)
Imbalance, not spellsProgressive asymmetric SNHL, poor speech discrimination

Tap a mimic to reveal the key discriminator.

When to step outside the criteria

Asymmetry of hearing out of proportion to the history, rapidly progressive or bilateral loss, or any focal neurological sign should prompt MRI of the internal auditory canals and appropriate work-up rather than a Ménière’s label. Pure positional, seconds-long spells belong to BPPV; a single prolonged first attack with an abnormal head-impulse test belongs to vestibular neuritis — and see the HINTS chapter.

Key points

  • Ménière’s is a diagnosis of exclusion — duration and the hearing picture discriminate most.
  • Vestibular migraine is the key contrast (hearing spared, migraine link) and a frequent coexister.
  • Consider SSCD (air–bone gap with normal reflexes) and vestibular schwannoma (progressive asymmetric loss).
  • Rapidly progressive or bilateral loss raises autoimmune inner-ear disease — and the need to image.