What is the recommended management for vestibular neuritis?

Management of Vestibular Neuritis

For vestibular neuritis, use short-term vestibular suppressants (meclizine 25-100 mg daily) and antiemetics only during the acute phase (first few days), then discontinue them immediately to avoid delaying central compensation, while encouraging early mobilization and vestibular rehabilitation. 1

Acute Phase Management (First 3-5 Days)

Symptomatic Control

• Vestibular suppressants like meclizine (25-100 mg daily in divided doses) may be used for severe vertigo, but only during the acute phase. 1, 2
• Antiemetics such as prochlorperazine should be reserved for severe nausea and vomiting during the acute phase only. 1
• Critical pitfall: Continuing vestibular suppressants beyond the acute phase (3-5 days) delays recovery by interfering with the brain's natural compensation mechanisms. 1, 3
• If meclizine worsens symptoms or causes excessive drowsiness, discontinue it immediately. 1

Meclizine Precautions

• Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects. 3, 2
• Warn patients about drowsiness, cognitive deficits, increased fall risk (especially in elderly), and avoid driving or operating machinery. 3, 2
• Avoid concurrent use with alcohol or other CNS depressants. 2
• Monitor for drug interactions with CYP2D6 inhibitors. 2

Critical Diagnostic Exclusions

Before confirming vestibular neuritis, rule out stroke—particularly in patients with vascular risk factors, as cerebellar strokes can mimic vestibular neuritis. 1, 4

Red Flags Requiring Urgent Brain Imaging

• Downbeating nystagmus 1
• Direction-changing nystagmus without head position changes 1
• Gaze-evoked nystagmus 1
• Dysarthria, dysmetria, or dysphagia 1
• Any sensory or motor deficits 1
• Significant vascular risk factors (hypertension, diabetes, smoking, atrial fibrillation) 1, 4

Post-Acute Phase Management (After First Week)

Vestibular Rehabilitation Therapy

• Encourage early resumption of normal physical activity immediately after the acute phase to promote central compensation. 4, 5
• Vestibular rehabilitation therapy should be initiated as soon as vestibular suppressants are discontinued. 3, 4, 6
• Physical activity is more important than any specific type of rehabilitation for long-term symptomatic recovery. 5
• Customized vestibular exercises can further accelerate compensation for patients with persistent symptoms. 6, 5

Specific Drug Therapy Considerations

• Corticosteroids (if initiated within 3 days of onset) may accelerate recovery of vestibular function in otherwise healthy individuals, though long-term benefit is uncertain. 4
• Withhold steroids from patients at higher risk of complications (diabetes, immunosuppression, severe hypertension). 4

Common Pitfalls to Avoid

• Never prescribe vestibular suppressants for chronic use—they impede central compensation and prolong disability. 1, 4
• Do not assume all acute vertigo is benign vestibular neuritis; always assess for central causes, especially with vascular risk factors. 1, 4
• Avoid prolonged bed rest, as it delays compensation; encourage mobilization as soon as the acute phase resolves. 4, 5
• Do not rely solely on vestibulo-ocular reflex testing to assess recovery; use symptomatic scales and posturography for comprehensive evaluation. 5

Follow-Up Protocol

• Reassess patients within 1 month to document resolution or persistence of symptoms. 3
• For incomplete recovery, intensify vestibular rehabilitation or refer to specialized vestibular physical therapy. 3, 5
• Patients with absent cervical vestibular evoked myogenic potentials (cVEMP) have worse prognosis and may require more aggressive rehabilitation. 5