What is the initial treatment for vestibular neuritis?

Initial Treatment for Vestibular Neuritis

The initial treatment for vestibular neuritis should include oral corticosteroids started within the first 3 days of symptom onset, along with short-term use of vestibular suppressants for symptomatic relief. 1

Diagnostic Considerations

Before initiating treatment, it's crucial to confirm the diagnosis of vestibular neuritis:

• Characteristic presentation: Acute onset of continuous rotatory vertigo lasting several days
• Horizontal spontaneous nystagmus toward the unaffected ear
• Pathologic head-impulse test toward the affected ear
• No hearing loss or other neurological symptoms
• No positional component to vertigo (to differentiate from BPPV)

Important Differential Diagnosis

• Central causes (stroke, hemorrhage) - especially in patients with vascular risk factors
• Vestibular migraine
• Early Ménière's disease
• BPPV

Treatment Algorithm

1. Corticosteroid Therapy

• Initiate oral corticosteroids within 3 days of symptom onset
• This accelerates recovery of vestibular function 1
• Recommended for otherwise healthy individuals
• Consider withholding in patients with contraindications or at higher risk of steroid complications

2. Symptomatic Treatment

• Vestibular suppressants: Use for short-term management (first few days only)
  • Meclizine 25-100 mg daily in divided doses 2
  • Benzodiazepines (e.g., diazepam, clonazepam)
  • Antihistamines (e.g., diphenhydramine)
• Antiemetics: For nausea and vomiting
  • Promethazine or ondansetron

3. Early Mobilization

• Encourage resumption of normal activity as soon as possible
• Avoid prolonged bed rest
• Early mobilization promotes central vestibular compensation

4. Vestibular Rehabilitation

• Initiate early vestibular rehabilitation exercises
• Helps promote central vestibular compensation
• Particularly important for patients with residual symptoms

Important Caveats and Pitfalls

1. Avoid prolonged use of vestibular suppressants

   • Should be withdrawn after the first several days
   • Prolonged use impedes central vestibular compensation 1
   • Only use for managing acute severe symptoms

2. Rule out central causes

   • Any patient with vascular risk factors should be evaluated for possible stroke
   • Central signs may not always be present initially

3. Antiviral therapy

   • Despite the suspected viral etiology (herpes simplex virus reactivation), evidence does not strongly support routine use of antivirals 3, 4

4. Follow-up assessment

   • Reassess within 1 month to document resolution or persistence of symptoms
   • Persistent symptoms may require additional vestibular rehabilitation

Special Considerations

• Elderly patients: May have delayed recovery and increased risk of falls
• Patients with pre-existing balance disorders: Higher risk of prolonged disability
• Patients with vascular risk factors: Require thorough evaluation to rule out stroke

By following this treatment approach, most patients recover well from vestibular neuritis, with improvement in symptoms typically occurring within days to weeks, although complete recovery may take several months.