What is the best management approach for vestibular neuritis?

Management of Vestibular Neuritis

For acute 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 nausea/vomiting, and begin vestibular rehabilitation therapy as soon as acute symptoms subside to promote central compensation. 1, 2, 3

Immediate Assessment and Red Flags

Before confirming vestibular neuritis, rule out life-threatening central causes that can mimic peripheral vestibular disorders:

• Exclude posterior circulation stroke, which presents identically to benign peripheral vestibular disorders in 10% of cases 4
• Look for central pathology red flags: 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 loss, Horner's syndrome) 4
• Any patient with significant vascular risk factors should be evaluated for possible stroke even if vestibular neuritis is suspected 2

Diagnostic Confirmation

• Vestibular neuritis presents with abrupt true-whirling vertigo lasting more than 24 hours, with no cochlear symptoms (hearing loss, tinnitus) and no other neurological symptoms or signs 3
• Perform head impulse test, bithermal caloric test, and vestibular-evoked myogenic potential test to confirm the diagnosis 3
• Do not routinely order vestibular function testing or electrocochleography to establish the diagnosis 5

Corticosteroid Therapy: Timing is Critical

The single most important treatment decision is initiating corticosteroids within 24 hours of symptom onset:

• 100% of patients treated within 24 hours achieved normal caloric test results at 3-month follow-up, compared to only 58% of those treated between 25-72 hours 1
• Recommended regimen: Oral prednisolone 50 mg daily for 5 days with tapering doses over the next 5 days 1
• For patients with severe nausea preventing oral intake, combine with initial intravenous betamethasone 8 mg for the first 1-2 days 1
• Withhold steroids from patients at higher risk of steroid complications unless presenting within the first 3 days 2

This represents the highest quality, most recent evidence (2019) demonstrating a dramatic effect based on treatment timing, making early steroid administration the cornerstone of management.

Vestibular Suppressants: Short-Term Use Only

Critical principle: Vestibular suppressants should be withdrawn as soon as possible, preferably after the first several days, because prolonged use impedes central vestibular compensation 2, 3:

• Use meclizine 25-100 mg daily in divided doses only for acute symptom control during the first 2-3 days 6, 7
• Antiemetics and vestibular suppressants are useful acutely but must be discontinued quickly 2
• Do not use vestibular suppressants as primary or prolonged treatment - they delay rather than enhance compensation 8
• Meclizine causes drowsiness, cognitive deficits, anticholinergic effects, and increased fall risk, particularly in elderly patients 7
• Prescribe with caution in patients with asthma, glaucoma, or prostate enlargement 6

Vestibular Rehabilitation: Essential for Recovery

Begin vestibular rehabilitation therapy as soon as acute symptoms subside to promote central compensation:

• Early resumption of normal activity should be encouraged to promote compensation 2
• Directed vestibular rehabilitation therapy further promotes the compensation process 2, 3
• Vestibular rehabilitation includes generalized vestibular exercises and customized vestibular exercises 3
• Most patients recover well from vestibular neuritis even without treatment, but rehabilitation accelerates recovery 2

Treatment Algorithm

1. First 24 hours: Initiate oral prednisolone 50 mg daily (or IV betamethasone 8 mg if unable to tolerate oral) + meclizine 25-100 mg daily for severe nausea/vomiting 1, 6

2. Days 2-3: Continue corticosteroids, begin tapering vestibular suppressants 2, 1

3. Days 4-5: Discontinue vestibular suppressants completely, continue corticosteroid taper 2

4. Days 6-10: Complete corticosteroid taper, encourage early resumption of normal activity 1, 2

5. Week 2 onward: Begin formal vestibular rehabilitation therapy if symptoms persist 2, 3

Follow-Up and Monitoring

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 7
• Perform caloric testing at 3 months to assess vestibular function recovery 1
• If symptoms persist beyond expected recovery period, evaluate for incomplete compensation or alternative diagnoses 2

Common Pitfalls to Avoid

• Missing the 24-hour window for steroid initiation - this dramatically reduces treatment efficacy from 100% to 58% 1
• Prolonged use of vestibular suppressants - this impedes central compensation and delays recovery 2, 8
• Failing to distinguish vestibular neuritis from central causes - always evaluate for stroke risk factors and central signs 2, 4
• Not initiating early vestibular rehabilitation - compensation is enhanced by directed therapy 2
• Prescribing meclizine to patients with contraindications (asthma, glaucoma, prostate enlargement) 6