What is the recommended treatment for a patient with vestibular neuritis?

Treatment of Vestibular Neuritis

For vestibular neuritis, use short-term vestibular suppressants (meclizine or benzodiazepines) only during the first few days for severe symptoms, then discontinue them promptly and transition to vestibular rehabilitation therapy to promote central compensation and recovery. 1, 2

Acute Phase Management (First 3-5 Days)

Symptomatic Medication

• Vestibular suppressants should be used only briefly (ideally 3-5 days maximum) to manage severe vertigo, nausea, and vomiting during the acute phase 1, 2
• Meclizine can be prescribed as-needed (PRN) rather than scheduled, typically 25-100 mg daily in divided doses, to avoid interfering with vestibular compensation 3, 1
• Benzodiazepines may be used short-term for severe vertigo symptoms and can help with psychological anxiety secondary to the acute vestibular crisis 3
• Prochlorperazine (5-10 mg orally or IV, maximum three doses per 24 hours) can be added for severe nausea or vomiting, but is not primary treatment for the vertigo itself 3, 4

Critical Timing Consideration

• Withdraw vestibular suppressants as soon as possible (preferably after the first several days) because prolonged use impedes central vestibular compensation, which is essential for recovery 1, 2, 5
• The American Academy of Otolaryngology-Head and Neck Surgery explicitly advises against routine long-term treatment with vestibular suppressants 1

Specific Drug Therapy

Corticosteroids

• Oral corticosteroids should be considered for otherwise healthy patients presenting within 3 days of symptom onset, as studies suggest they accelerate recovery of vestibular function with a recovery rate of 62% within 12 months 2, 5
• Withhold steroids from patients at higher risk of complications from steroid therapy 2

Antiviral Therapy

• The evidence for antiviral therapy remains uncertain, though HSV-1 reactivation is implicated in the pathophysiology 2, 5

Post-Acute Phase Management (After First Week)

Vestibular Rehabilitation

• Early resumption of normal activity should be encouraged immediately to promote central compensation 2
• Directed vestibular rehabilitation therapy is essential and should begin as soon as the acute symptoms subside, as it significantly promotes the compensation process 2, 6
• This includes both generalized vestibular exercises and customized vestibular rehabilitation programs 6

Important Safety Considerations

Medication Risks

• Vestibular suppressants cause significant side effects including drowsiness, cognitive deficits, and are an independent risk factor for falls, especially in elderly patients 3, 1
• Long-term use of vestibular suppressants interferes with central compensation, which is the primary mechanism for recovery in peripheral vestibular conditions 3

Differential Diagnosis Warning

• Brain imaging is indicated when the patient has: unprecedented headache, negative head impulse test (suggesting central pathology), severe unsteadiness, or no recovery within 1-2 days 7
• Central causes such as brainstem or cerebellar stroke can mimic vestibular neuritis and must not be missed, particularly in patients with vascular risk factors 2, 7

Follow-Up Protocol

• Reassess patients within 1 month after initial treatment to document resolution or persistence of symptoms 1, 4
• Transition from medication to vestibular rehabilitation when appropriate to promote long-term recovery 3, 4
• Patients should be educated about the natural course of vestibular neuritis, expected recovery timeline (most patients recover well even without treatment), and the critical importance of compliance with vestibular exercises 1, 2

Common Pitfalls to Avoid

• Do not prescribe vestibular suppressants on a scheduled basis - use PRN only to avoid impeding compensation 1
• Do not continue vestibular suppressants beyond the acute phase - this is the most common error that delays recovery 1, 2
• Do not rely solely on medication - vestibular rehabilitation is essential for optimal recovery 2, 6
• Do not miss central causes - maintain high suspicion for stroke in patients with vascular risk factors or atypical features 2, 7