What is the treatment for vestibular neuritis?

Treatment of Vestibular Neuritis

The first-line treatment for vestibular neuritis includes a short course of corticosteroids, vestibular rehabilitation, and limited use of vestibular suppressants only during the acute phase. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis through:

• Characteristic clinical features: abrupt-onset vertigo lasting >24 hours without cochlear symptoms or neurological signs 1
• Positive head impulse test toward the affected ear
• Horizontal-torsional spontaneous nystagmus beating away from the lesion side
• Unsteadiness with falling tendency toward the lesion side 3

Treatment Algorithm

Acute Phase (First 1-3 Days)

1. Corticosteroids

   • Oral steroids should be started within the first 3 days of symptom onset 2
   • Evidence shows steroids accelerate recovery of vestibular function 2
   • Withhold steroids in patients at higher risk of steroid complications

2. Symptomatic Relief (Short-term Only)

   • Vestibular suppressants (antihistamines, benzodiazepines) for severe vertigo
   • Antiemetics for nausea/vomiting
   • Important: Discontinue these medications after 2-3 days as prolonged use impedes central vestibular compensation 2
   • Avoid routine use of vestibular suppressant medications like antihistamines and benzodiazepines 4

3. Rule Out Central Causes

   • Brain imaging is indicated when patient has:
     • Unprecedented headache
     • Negative head impulse test
     • Severe unsteadiness
     • No recovery within 1-2 days 3
     • Significant vascular risk factors 2

Recovery Phase (Beyond 3 Days)

1. Vestibular Rehabilitation

   • Begin as soon as acute vertigo subsides
   • Promotes and accelerates central vestibular compensation 2
   • Early resumption of normal activity should be encouraged 2

2. Follow-up

   • Reassess within 1 month to confirm symptom resolution 4
   • Evaluate for persistent symptoms or development of BPPV (which can occur following vestibular neuritis)

Specific Medications to Avoid

• Do not routinely use vestibular suppressants (antihistamines like meclizine or benzodiazepines) beyond the first few days 4
• These medications can:
  • Interfere with central compensation
  • Cause drowsiness and impair driving ability 5
  • Lead to potential anticholinergic side effects (dry mouth, blurred vision, urinary retention) 5
  • Cause dependence (particularly with benzodiazepines)

Common Pitfalls to Avoid

1. Prolonged use of vestibular suppressants

   • Delays recovery by inhibiting central compensation 2
   • Can lead to medication dependence

2. Missing central causes of vertigo

   • Always consider stroke in patients with vascular risk factors presenting with acute vertigo 2
   • Central vertigo may lack the typical peripheral vestibular signs

3. Delayed initiation of vestibular rehabilitation

   • Early rehabilitation is key to promoting compensation 2

4. Failure to educate patients

   • Patients should understand the natural course of the condition
   • Most recover well even without treatment, but recovery can take weeks 2

Patient Education Points

• Explain that symptoms typically improve over days to weeks
• Emphasize the importance of early mobilization despite initial discomfort
• Advise about safety precautions during the acute phase
• Reassure that complete recovery occurs in most patients, though some may have residual symptoms

By following this treatment approach that emphasizes early corticosteroid use, limited vestibular suppressant use, and vestibular rehabilitation, most patients with vestibular neuritis will experience significant improvement in symptoms and quality of life.