What is the recommended treatment for vestibular neuritis, including available medication options in Canada?

Treatment of Vestibular Neuritis

For vestibular neuritis, the recommended treatment includes short-term vestibular suppressants (meclizine), a course of oral corticosteroids, and vestibular rehabilitation therapy. 1, 2

Diagnosis Confirmation

Before initiating treatment, confirm the diagnosis with these key features:

• Acute onset of vertigo lasting >24 hours
• Horizontal-torsional nystagmus beating away from the affected side
• Abnormal head impulse test toward the affected side
• No hearing loss or other neurological symptoms
• HINTS examination to rule out central causes (sensitivity 92.9%, specificity 83.4%) 1, 2

Acute Phase Management

1. Symptomatic Treatment

   • Meclizine (Antivert): 25-100 mg daily in divided doses 3
     • Available in Canada as 12.5 mg, 25 mg, and 50 mg tablets
     • Limit use to <1 week to avoid interference with vestibular compensation 1
     • Take caution with driving or operating machinery due to drowsiness 3
     • Contraindicated in patients with hypersensitivity to meclizine 3

2. Specific Drug Therapy

   • Corticosteroids: Recommended for patients presenting within 3 days of symptom onset 4
     • Accelerates recovery of vestibular function 4
     • Improves recovery rate to 62% within 12 months 5
     • Withhold in patients at higher risk of steroid complications 4

3. Supportive Care

   • Antiemetics for nausea and vomiting
   • Adequate hydration
   • Early mobilization to promote central compensation 4

Recovery Phase Management

1. Vestibular Rehabilitation Therapy

   • Begin as soon as acute vertigo symptoms start to subside 1, 4
   • Includes:
     • Gaze stabilization exercises
     • Balance training
     • Habituation exercises
     • Walking with head movements
   • Promotes central vestibular compensation 4
   • Long-term outcomes equivalent to corticosteroids 6

2. Medication Tapering

   • Discontinue vestibular suppressants after the first several days 4
   • Prolonged use impedes central vestibular compensation 1, 4

Follow-up and Monitoring

• Reassess within 1 month to document resolution or persistence of symptoms 1
• Monitor for potential complications:
  • Persistent imbalance
  • Benign paroxysmal positional vertigo as a sequela
  • Incomplete recovery requiring additional rehabilitation

Special Considerations

• Elderly patients: Higher risk of falls; may require modified rehabilitation techniques 1
• Patients with vascular risk factors: Consider brain imaging to rule out stroke 4
• Patients with asthma, glaucoma, or prostate enlargement: Use meclizine with caution due to anticholinergic effects 3

Common Pitfalls to Avoid

1. Prolonged use of vestibular suppressants beyond 1 week
2. Failure to initiate vestibular rehabilitation
3. Misdiagnosis of central vestibular disorders as vestibular neuritis
4. Delayed treatment with corticosteroids (most effective when started within 3 days)
5. Bed rest, which delays recovery; early mobilization is key

Most patients recover well from vestibular neuritis even without treatment, but appropriate management can accelerate recovery and improve outcomes 4.