The efficacy of medical treatment in preventing the need for vestibular neurectomy (VN) in patients with disabling Ménière's disease, and in facilitating postoperative compensation of equilibrium after VN, was investigated. Ninety-five patients with classic symptoms of unilateral incapacitating Ménière's disease were included. Patients were treated with either 16 mg betahistine three-times daily (n = 49) or 125 mg acetazolamide once-daily (n = 46) for 6 months. The study showed that marked benefit was achieved in 51 of the 95 patients, of whom significantly more were in the betahistine group than in the acetazolamide group [32 (65%) vs 19 (41%); p < 0.05]. Twenty-seven patients in the acetazolamide group and 17 in the betahistine group experienced no benefit from medical treatment and therefore underwent VN. Twelve patients in the betahistine group and 6 in the acetazolamide group eventually experienced a relapse and thus also underwent VN. Therefore 62 patients in total underwent VN. Following surgery, patients were given medical treatment in an attempt to facilitate vestibular compensation; 28 received betahistine (16 mg three-times daily) and 34 received cinnarizine (25 mg three-times daily) for 3 months. The patients treated with betahistine had a shorter period of disability and significantly better results on rotatory testing. In conclusion we recommend the use of betahistine in patients who have undergone VN.