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 symptomatic management using vestibular suppressants such as meclizine (25-100 mg daily in divided doses) for vertigo and antiemetics for nausea. 1, 2

Diagnosis and Evaluation

Before initiating treatment, it's crucial to distinguish vestibular neuritis from central causes of vertigo:

• Vestibular neuritis presents with:

  • Sudden onset rotational vertigo lasting several days
  • Horizontal spontaneous nystagmus toward the unaffected ear
  • Normal hearing (no associated cochlear symptoms)
  • Normal neurological examination (except for vestibular findings)
  • Nausea and vomiting
  • Postural imbalance with falls toward the affected ear 3

• Red flags suggesting central vertigo requiring urgent neuroimaging:

  • Gradual onset vertigo
  • Persistent symptoms
  • Associated neurological symptoms
  • Nystagmus that doesn't suppress with visual fixation
  • Abnormal neurological examination 4

Treatment Algorithm

1. Corticosteroid Therapy

• Start oral corticosteroids within 3 days of symptom onset
• Studies suggest steroids accelerate recovery of vestibular function
• Reasonable to treat otherwise healthy individuals presenting within 3 days
• Consider withholding steroids in patients at higher risk of steroid complications 1

2. Symptomatic Management

• Vestibular suppressants:

  • Meclizine: 25-100 mg daily in divided doses 2
  • Use only for the first few days (typically 1-3 days)
  • Important: Prolonged use may impede central vestibular compensation 1

• Antiemetics:

  • Prokinetic antiemetics (e.g., domperidone, metoclopramide) may be useful for managing nausea without significantly interfering with vestibular compensation 4

3. Early Mobilization and Vestibular Rehabilitation

• Encourage early resumption of normal activity to promote central compensation
• Initiate vestibular rehabilitation exercises as soon as acute symptoms begin to subside
• Directed vestibular rehabilitation therapy can further promote the compensation process 1

Important Considerations and Pitfalls

Medication Cautions

• Limit duration of vestibular suppressants:

  • Prolonged use impedes central vestibular compensation
  • Withdraw as soon as possible, preferably after the first several days 1

• Meclizine side effects:

  • May cause drowsiness - caution when driving or operating machinery
  • Has anticholinergic effects - use with care in patients with asthma, glaucoma, or prostate enlargement
  • Common adverse reactions include drowsiness, dry mouth, headache, fatigue, and vomiting 2

• Drug interactions:

  • Avoid coadministration of meclizine with other CNS depressants, including alcohol
  • Be aware of potential interactions with CYP2D6 inhibitors 2

Differential Diagnosis

• Rule out vestibular pseudoneuritis due to acute brainstem lesions or cerebellar infarctions
• Consider vestibular migraine and early Ménière's disease in the differential diagnosis
• Patients with significant vascular risk factors should be evaluated for possible stroke, as central causes can mimic peripheral vertigo 1, 3

Prognosis

• Most patients recover well from vestibular neuritis, even without treatment
• Recovery occurs through a combination of:
  • Peripheral restoration of labyrinthine function (usually incomplete)
  • Somatosensory and visual substitution
  • Central compensation 3

Follow-up Care

• Monitor for symptom resolution
• Assess for development of benign paroxysmal positional vertigo (BPPV), which can occur as a complication
• Continue vestibular rehabilitation if symptoms persist
• Patient education about possible recurrence and safety measures to prevent falls 4