Is prednisone (corticosteroid) indicated for treatment of vestibular neuritis?

Prednisone for Vestibular Neuritis

Prednisone (or methylprednisolone) is indicated for vestibular neuritis and significantly improves peripheral vestibular function recovery, though vestibular rehabilitation therapy is equally effective long-term and should be the primary treatment option, with corticosteroids added when not contraindicated to accelerate early recovery. 1, 2

Evidence for Corticosteroid Use

The strongest evidence comes from a high-quality randomized controlled trial demonstrating that methylprednisolone significantly improves recovery of peripheral vestibular function (mean improvement 62.4% vs 39.6% with placebo, P<0.001), while antiviral therapy (valacyclovir) provides no benefit. 1

Key Clinical Points:

• Corticosteroids accelerate objective vestibular recovery measured by caloric testing, particularly in the first 1-6 months after onset 1, 3, 4
• The benefit is most pronounced for canal paresis improvement at 1 month (significantly better than vestibular rehabilitation alone) 2
• However, by 12 months, outcomes are equivalent whether patients receive corticosteroids, vestibular rehabilitation, or combination therapy 3, 4, 2

Critical Treatment Algorithm

Acute Phase (First 3-5 Days):

1. Initiate corticosteroids (methylprednisolone or prednisone equivalent) if no contraindications exist 1, 2
2. Use vestibular suppressants (meclizine) only as needed for severe vertigo, nausea, and vomiting—not on a scheduled basis 5, 6
3. Withdraw vestibular suppressants as soon as possible (ideally after first several days) to avoid impeding central vestibular compensation 5, 6, 7

Post-Acute Phase (After Initial Days):

1. Begin vestibular rehabilitation exercises early, even while still symptomatic 8, 3
2. Discontinue vestibular suppressants to allow central compensation mechanisms to function 6, 7
3. Continue vestibular exercises as the primary long-term intervention 3, 4, 2

Comparative Effectiveness

Vestibular rehabilitation therapy provides better subjective improvement (Dizziness Handicap Inventory scores) at 1 month compared to corticosteroids alone (-3.95 point difference, P=0.04). 2

Combination therapy (corticosteroids + VRT) shows better subjective outcomes than corticosteroids alone at 3 months (3.15 point DHI improvement, P=0.0002). 2

The practical implication: corticosteroids enhance earlier objective recovery (canal function), while VRT provides earlier subjective symptom relief. 2

Important Caveats

What NOT to Do:

• Never use long-term vestibular suppressants (antihistamines, benzodiazepines) as they interfere with central compensation and increase fall risk 5, 6, 7
• Do not use antiviral therapy (valacyclovir)—it provides no benefit despite the presumed viral etiology 1
• Avoid scheduled dosing of meclizine—use only PRN for severe symptoms 5, 7

Reassessment:

Patients must be reassessed within 1 month after initial treatment to document resolution or persistence of symptoms and adjust therapy accordingly. 5, 6, 7

Clinical Decision Framework

For patients presenting within 3 days of symptom onset:

• Offer corticosteroids to accelerate recovery if no contraindications 1, 2
• Simultaneously initiate vestibular rehabilitation exercises 2
• Provide PRN vestibular suppressants for severe symptoms only 5, 7

For patients with contraindications to corticosteroids:

• Vestibular rehabilitation therapy alone is equally effective long-term 3, 4, 2
• Recovery may be slightly slower initially but outcomes at 12 months are equivalent 2