Initial Treatment for Vestibular Neuronitis
The initial treatment for vestibular neuronitis should include corticosteroids (if presenting within 3 days of symptom onset and no contraindications exist), short-term vestibular suppressants for severe nausea/vomiting only (discontinued within several days), and early vestibular rehabilitation therapy to promote central compensation. 1, 2, 3
Corticosteroid Therapy
Oral corticosteroids (e.g., prednisolone for 10 days) should be initiated in otherwise healthy patients who present within 3 days of symptom onset, as they accelerate recovery of vestibular function with an odds ratio of 2.4 for restoration of vestibular function at follow-up (95% CI 1.3-4.4; NNT = 7). 2, 3
Withhold steroids from patients at higher risk of steroid-related complications (diabetes, immunosuppression, severe hypertension). 1
The benefit is most pronounced in the acute phase (OR 3.1,95% CI 1.2-7.8; NNT = 6), though the evidence base has heterogeneity and mostly low-grade quality studies. 2
Vestibular Suppressant Medications: Critical Limitations
Avoid benzodiazepines for routine treatment of vestibular neuronitis, as they impede central vestibular compensation. 4
Antiemetics and vestibular suppressants (including meclizine) may be used acutely for severe nausea and vomiting but must be withdrawn as soon as possible, preferably after the first several days, because prolonged use impedes central vestibular compensation. 1
While meclizine is FDA-approved for vertigo associated with vestibular system diseases 5, its use should be strictly time-limited in vestibular neuronitis to avoid interfering with recovery.
Vestibular Rehabilitation Therapy
Early vestibular rehabilitation should be initiated as soon as the acute symptoms begin to subside, as it significantly reduces perceived dizziness at 3 months (p = 0.007) and 12 months (p = 0.001) compared to standard care alone. 3
Vestibular rehabilitation can include Cawthorne-Cooksey exercises (eye, head, and body movements in increasing difficulty) performed until symptoms fatigue, forcing central nervous system compensation through habituation. 6
Early resumption of normal activity should be actively encouraged to promote central compensation, rather than prolonged bed rest. 1
Supervised exercise therapy, individually tailored and supported by home exercises, is more effective than standard care alone for reducing dizziness handicap and improving daily function. 3
Critical Diagnostic Consideration
Any patient with significant vascular risk factors presenting with acute vestibular syndrome must be evaluated for possible stroke (brainstem or cerebellar), as definitive central signs are not always present and missing a stroke could be life-threatening. 4, 1
Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms. 4
Common Pitfalls to Avoid
Do not continue vestibular suppressants beyond the first several days, as this is the most common error that delays recovery by preventing central compensation. 1
Do not prescribe corticosteroids to patients presenting more than 3 days after symptom onset, as the benefit is uncertain and risk may outweigh benefit. 1
Do not assume all acute vertigo is benign vestibular neuronitis—always consider central causes, especially in patients with vascular risk factors. 4, 1