What is the initial treatment for vestibular neuritis?

Initial Treatment for Vestibular Neuritis

The initial treatment for vestibular neuritis should include oral prednisone starting at 60 mg daily with a taper over 10-14 days, especially for patients with severe symptoms, along with short-term vestibular suppressants for symptom management. 1

Pharmacological Management

First-Line Treatment

• Corticosteroids:
  • Oral prednisone 60 mg daily with taper over 10-14 days
  • Should be initiated within the first 3 days of symptom onset for maximum benefit
  • Accelerates recovery of vestibular function 2
  • Most effective when started early in otherwise healthy individuals

Symptomatic Relief

• Vestibular suppressants:

  • Meclizine (FDA-approved for vertigo associated with vestibular system diseases) 3
  • Diazepam 2-5 mg orally 1-3 times daily as needed (use lower doses in elderly)
  • Should be limited to short-term use (≤1 week) to prevent interference with vestibular compensation 1

• Antiemetics:

  • Prochlorperazine 25 mg oral or suppository for associated nausea and vomiting 1

Important Treatment Considerations

Timing of Medication

• Vestibular suppressants and antiemetics:
  • Use only during the first several days of acute symptoms
  • Prolonged use may impede central vestibular compensation 2
  • Should be withdrawn as soon as possible after acute phase

Treatment Limitations

• Consider withholding steroids in patients at higher risk for steroid complications 2
• For patients not responding to oral therapy, intratympanic steroid injections may be considered 1

Rehabilitation Phase

• Early mobilization:

  • Encourage resumption of normal activities as soon as tolerated
  • Promotes central vestibular compensation 2

• Vestibular rehabilitation therapy:

  • Should be initiated after the acute phase has resolved
  • Not recommended during acute vertigo attacks 1
  • Individually tailored exercises have been shown to reduce perception of dizziness and improve function at 3 and 12 months 4

Follow-up Care

• Reassess patients within 1 month after treatment to:
  • Confirm symptom resolution
  • Evaluate for persistent symptoms that may indicate treatment failure
  • Rule out other vestibular conditions or CNS disorders 1

Potential Pitfalls

• Misdiagnosis: Ensure central causes of vertigo (stroke, cerebellar hemorrhage) are ruled out, especially in patients with vascular risk factors 2
• Prolonged vestibular suppressant use: Can delay recovery by interfering with central compensation mechanisms
• Delayed rehabilitation: Failure to implement vestibular exercises after the acute phase can lead to prolonged symptoms
• Inadequate follow-up: Missing the 1-month follow-up may result in failure to identify persistent symptoms requiring additional intervention

By following this treatment algorithm, clinicians can optimize outcomes for patients with vestibular neuritis while minimizing morbidity and improving quality of life.