What is the initial treatment for Vestibular Neuritis?

Initial Treatment for Vestibular Neuritis

The initial treatment for vestibular neuritis should include a short course of oral corticosteroids (such as prednisone or methylprednisolone) for 7-14 days with tapering dose, started as early as possible (ideally within 24 hours of symptom onset), along with short-term vestibular suppressants for symptomatic relief. 1, 2

Pharmacological Management

First-line Treatment:

• Corticosteroids:
  • Oral prednisone 50 mg/day for 5 days with tapering over the next 5 days 2
  • Should be initiated as early as possible, preferably within 24 hours of symptom onset
  • Early steroid treatment (within 24 hours) results in significantly better vestibular function recovery (100% normal caloric test results) compared to delayed treatment (58% normal results) 2

Symptomatic Relief (short-term use only):

• Vestibular suppressants should be used only for the first few days to manage acute symptoms 1, 3:
  • Antihistamines (e.g., meclizine) - FDA-approved for vertigo associated with vestibular system diseases 4
  • Benzodiazepines (e.g., lorazepam) for severe vertigo
  • Dopamine receptor antagonists (e.g., prochlorperazine, metoclopramide) for associated nausea
  • Important caveat: Prolonged use beyond a few days may impede central vestibular compensation 3, 5

Non-pharmacological Management

Vestibular Rehabilitation:

• Early resumption of normal activity should be encouraged to promote central compensation 3
• Directed vestibular rehabilitation exercises should be initiated once acute symptoms begin to subside 6
• Both generalized and customized vestibular exercises can be beneficial 6

Patient Education:

• Explain the likely viral etiology and generally favorable prognosis 7
• Emphasize the importance of:
  • Limiting vestibular suppressant use to the acute phase only
  • Gradually increasing activity to promote compensation
  • Fall prevention strategies, especially for elderly patients 1

Clinical Pearls and Pitfalls

Important Diagnostic Considerations:

• Rule out central causes of vertigo (stroke or hemorrhage) before confirming diagnosis, especially in patients with vascular risk factors 3
• The HINTS examination (Head-Impulse, Nystagmus, Test of Skew) is more sensitive than early MRI for detecting stroke (100% vs 46%) 1

Treatment Timing:

• The timing of steroid administration appears critical - treatment within 24 hours of symptom onset shows significantly better outcomes than delayed treatment 2
• Studies suggest that steroids accelerate recovery of vestibular function, though their impact on long-term outcomes is less certain 3

Treatment Contraindications:

• Consider withholding steroids in patients at higher risk for steroid complications 3
• If bacterial labyrinthitis is suspected, appropriate antibiotic therapy should be initiated 1

By following this evidence-based approach with early corticosteroid treatment and short-term symptomatic management, followed by vestibular rehabilitation, most patients with vestibular neuritis can achieve good recovery of vestibular function and symptomatic relief.