What is the best management approach for vestibular neuritis?

Management of Vestibular Neuritis

For vestibular neuritis, initiate oral corticosteroids within 24 hours of symptom onset (prednisolone 50 mg daily for 5 days with tapering over the next 5 days), use vestibular suppressants only for the first 2-3 days to control severe symptoms, and begin vestibular rehabilitation therapy as soon as acute symptoms subside to promote central compensation. 1, 2, 3

Immediate Assessment and Diagnosis

Before treating presumed vestibular neuritis, you must first exclude central causes that can mimic this condition:

• Rule out posterior circulation stroke, which presents identically to peripheral vestibular disorders in 10% of cerebellar strokes—this is the most dangerous diagnostic pitfall 4
• Look for red flags indicating central pathology: downbeating nystagmus without torsional component, direction-changing nystagmus without head position changes, baseline nystagmus without provocative maneuvers, or associated posterior circulation signs (dysarthria, dysmetria, dysphagia, sensory/motor deficits, Horner's syndrome) 4
• Confirm the diagnosis with characteristic findings: acute-onset rotatory vertigo lasting more than 24 hours, horizontal spontaneous nystagmus toward the unaffected ear, pathologic head-impulse test toward the affected ear, postural imbalance with falls toward the affected ear, and critically—no cochlear symptoms or other neurological deficits 5, 3

Specific Drug Therapy: Corticosteroids

Timing is critical for steroid efficacy:

• Initiate corticosteroids within 24 hours of symptom onset for optimal vestibular function recovery—100% of patients treated within 24 hours achieved normal caloric test results at 3 months, compared to only 58% of those treated between 25-72 hours 2
• Use oral prednisolone 50 mg daily for 5 days, then taper over the next 5 days 2
• If the patient presents with severe nausea/vomiting, combine with intravenous betamethasone 8 mg for the first 1-2 days 2
• Steroids accelerate recovery of vestibular function with a 62% recovery rate within 12 months, though their effect on long-term outcome remains uncertain 1, 3
• Withhold steroids from patients at higher risk of steroid complications (uncontrolled diabetes, severe osteoporosis, active infections) 1

The evidence strongly supports early steroid intervention, with the most recent high-quality study demonstrating a statistically significant difference based on treatment timing 2.

Symptomatic Management: Vestibular Suppressants

Strictly limit vestibular suppressant use to avoid impeding central compensation:

• Use meclizine 25-100 mg daily in divided doses, antihistamines, or benzodiazepines only for the first 2-3 days to control severe acute vertigo, nausea, and vomiting 6, 1, 7
• Discontinue vestibular suppressants as soon as possible—prolonged use impedes central vestibular compensation, which is essential for long-term recovery 1, 7, 5
• Meclizine causes drowsiness and has anticholinergic effects; prescribe with caution in patients with asthma, glaucoma, or prostate enlargement 6
• These medications are particularly problematic in elderly patients due to increased fall risk, cognitive deficits, and anticholinergic side effects 8

Vestibular Rehabilitation Therapy

Early mobilization and structured vestibular exercises are crucial for recovery:

• Encourage early resumption of normal activity as soon as the acute phase subsides (typically after 2-3 days) to promote central vestibular compensation 1, 3
• Initiate directed vestibular rehabilitation therapy, which includes generalized vestibular exercises and customized exercises tailored to the patient's specific deficits 5, 3
• Vestibular rehabilitation promotes central compensation through somatosensory and visual substitution mechanisms 3
• This therapy is particularly beneficial for patients with persistent dizziness, postural instability, or incomplete recovery after the acute phase 8

Treatment Algorithm

1. First 24 hours: Confirm diagnosis, exclude central causes, initiate oral corticosteroids (prednisolone 50 mg daily), use vestibular suppressants only for severe symptoms 1, 2, 3
2. Days 2-3: Continue corticosteroids, begin tapering vestibular suppressants, encourage gradual mobilization 1, 2
3. Days 4-5: Complete corticosteroid course, discontinue vestibular suppressants, initiate vestibular rehabilitation exercises 1, 5
4. Days 6-10: Taper corticosteroids, continue vestibular rehabilitation 2
5. Follow-up at 3 months: Assess vestibular function recovery with caloric testing if symptoms persist 2, 3

Common Pitfalls to Avoid

• Missing posterior circulation stroke—maintain high suspicion in patients with vascular risk factors, atypical nystagmus patterns, or any central neurological signs 4, 1
• Delaying corticosteroid treatment beyond 24 hours—efficacy drops significantly after the first day 2
• Prolonged use of vestibular suppressants—this actively impairs the brain's natural compensation mechanisms and delays recovery 1, 7
• Failing to initiate early vestibular rehabilitation—passive rest beyond the first few days prolongs disability 1, 3
• Not reassessing patients who fail to improve—persistent symptoms warrant investigation for incomplete recovery, bilateral involvement, or alternative diagnoses 3