Steroid Dosing for Severe Vestibular Vertigo
For severe vestibular vertigo, intratympanic dexamethasone (4-24 mg/mL) or methylprednisolone (30-62.5 mg/mL) should be administered at a volume of 0.4-0.8 mL into the middle ear space, with 3-4 sessions every 3-7 days depending on clinical response. 1
Diagnosis and Treatment Algorithm
Step 1: Determine Specific Vestibular Diagnosis
- Distinguish between different causes of vertigo:
- Ménière's disease: Episodic vertigo with fluctuating hearing loss, tinnitus, aural fullness
- Vestibular neuritis: Acute prolonged vertigo without hearing loss
- BPPV: Brief positional vertigo lasting seconds to minutes
- Labyrinthitis: Sudden severe vertigo with hearing loss
Step 2: Steroid Treatment Protocol Based on Diagnosis
For Ménière's Disease:
Intratympanic (IT) steroid therapy:
- Dexamethasone: 4-24 mg/mL (stock or compounded)
- Methylprednisolone: 30-62.5 mg/mL (stock or compounded)
- Volume: 0.4-0.8 mL injected into middle ear space
- Frequency: 3-4 sessions every 3-7 days 1
Oral steroid alternative:
- Prednisone: 0.35 mg/kg daily for up to 18 weeks 2
- This regimen has shown to reduce frequency and duration of vertigo episodes by 50% and 30% respectively
For Vestibular Neuritis:
- Methylprednisolone: Initial high dose (32 mg/day) with tapering over 3-4 weeks 3, 4
- Corticosteroid therapy enhances earlier resolution of symptoms compared to vestibular exercises alone
Efficacy and Evidence Considerations
- IT steroid therapy shows 31-90% complete vertigo control in Ménière's disease 1
- IT steroids have lower risk of hearing loss (0-8%) compared to gentamicin therapy (12.5-15.4%) 1
- Oral prednisone helps control refractory vertigo in Ménière's disease with minimal side effects 2
- Methylprednisolone is significantly more effective than placebo in reducing vertiginous symptoms in acute vestibular vertigo 3
Important Caveats and Precautions
- Vestibular suppressant medications (antihistamines, benzodiazepines) should not be used as primary treatment for vertigo but may be appropriate for short-term management of severe vegetative symptoms (nausea, vomiting) 1
- These medications can interfere with central compensation in peripheral vestibular conditions
- Steroid therapy is most effective when initiated early (ideally within first 14 days of symptom onset) 1
- Reassess patients within 1 month after initial treatment to confirm symptom resolution 1
- For patients with BPPV, repositioning maneuvers are preferred over medication therapy 1
Treatment Duration Considerations
- For acute vestibular vertigo: Short course of high-dose steroids with taper over 3-4 weeks
- For Ménière's disease: IT injections typically require 3-4 sessions
- For refractory cases: Extended oral prednisone therapy may be considered (up to 18 weeks) 2
The evidence suggests that early intervention with appropriate steroid therapy significantly improves outcomes in severe vestibular vertigo, with the specific regimen depending on the underlying diagnosis.