What is the initial treatment for vestibular neuronitis?

Initial Treatment for Vestibular Neuronitis

For acute vestibular neuronitis, initiate oral corticosteroids (prednisolone 50 mg daily for 5 days with tapering over the next 5 days) within 24 hours of symptom onset for optimal vestibular recovery, combined with short-term vestibular suppressants for severe symptoms only, followed by early vestibular rehabilitation therapy. 1, 2

Immediate Pharmacologic Management

Corticosteroid Therapy (Primary Treatment)

• Start prednisolone 50 mg orally daily for 5 days, then taper over the next 5 days 2
• Timing is critical: treatment within 24 hours of onset results in 100% normalization of caloric testing at 3 months, compared to only 58% when started between 25-72 hours 2
• If the patient presents with severe nausea/vomiting preventing oral intake, add intravenous betamethasone 8 mg for the first 1-2 days 2
• Corticosteroids accelerate recovery of vestibular function, though their effect on long-term outcomes remains uncertain 1

Symptomatic Relief (Short-Term Only)

• Use vestibular suppressants (antihistamines like meclizine 25-100 mg daily in divided doses) or antiemetics only for the first several days 3, 1
• Meclizine is FDA-approved for vertigo associated with vestibular system diseases 3
• Discontinue vestibular suppressants as soon as tolerable (preferably after 2-3 days maximum) because prolonged use impedes central vestibular compensation 1, 4
• Avoid benzodiazepines for routine treatment 5

Early Mobilization and Vestibular Rehabilitation

Immediate Activity Resumption

• Encourage return to normal physical activity as soon as the acute phase subsides (within days) to promote central compensation 1, 6
• Physical activity is more important than any specific rehabilitation technique for long-term symptomatic improvement 6

Vestibular Rehabilitation Therapy Protocol

• Initiate supervised vestibular rehabilitation therapy early (within the first week) in addition to corticosteroids 7
• This combination reduces perceived dizziness at 3 months (p=0.007) and 12 months (p=0.001) compared to standard care alone 7
• VRT should include Cawthorne-Cooksey exercises: progressive eye, head, and body movements performed until symptoms fatigue, forcing central nervous system compensation through habituation 8
• Home-based therapy is equally effective as clinician-supervised therapy after initial instruction 8
• VRT improves anxiety/depression scores (HADS, p=0.039) and reduces dizziness handicap (DHI, p=0.049) at 12 months 7

Critical Differential Diagnosis Considerations

Rule Out Central Causes First

• Before diagnosing vestibular neuronitis, exclude brainstem or cerebellar stroke, which can be life-threatening 1
• Any patient with significant vascular risk factors (hypertension, diabetes, hyperlipidemia, smoking) presenting with acute vestibular syndrome should be evaluated for possible stroke 5, 1
• Red flags for central pathology include: associated neurologic symptoms (hemiparesis, sensory loss, ataxia, Horner's syndrome), hearing loss, or severe headache 5, 1

Confirm Peripheral Vestibular Pattern

• Vestibular neuronitis presents with: abrupt true-whirling vertigo lasting >24 hours, horizontal-torsional nystagmus beating away from the affected side, positive head impulse test toward the affected side, and no cochlear symptoms or other neurological signs 4
• The absence of auditory symptoms distinguishes vestibular neuronitis from labyrinthitis 4

Follow-Up and Reassessment

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 5, 9
• Most patients recover well even without treatment, but corticosteroids accelerate this process 1
• For persistent symptoms beyond 1 month, evaluate for incomplete compensation, coexisting vestibular disorders, or missed central pathology 9

Common Pitfalls to Avoid

• Do not continue vestibular suppressants beyond the first few days—this is the most common error that delays compensation 1, 4
• Do not delay corticosteroid initiation—every hour counts, with optimal results only when started within 24 hours 2
• Do not miss a posterior circulation stroke—approximately 10% of cerebellar strokes present similarly to peripheral vestibular processes 9
• Do not prescribe bed rest—early mobilization is essential for compensation 1, 6