What is the appropriate workup and management for an otherwise healthy adult presenting with acute vestibular neuritis (sudden severe vertigo, nausea, vomiting, gait instability, horizontal‑rotatory nystagmus, no hearing loss)?

Vestibular Neuritis: Workup and Management

For an otherwise healthy adult presenting with acute vestibular neuritis, perform a focused bedside examination to exclude stroke, provide symptomatic relief with antiemetics and vestibular suppressants for 2–3 days only, initiate corticosteroids within 72 hours of symptom onset, and begin early vestibular rehabilitation therapy.

Initial Clinical Assessment

Confirm the diagnosis by identifying the characteristic triad: sudden-onset continuous rotatory vertigo lasting days, horizontal-rotatory nystagmus beating away from the affected ear, and absence of hearing loss or other neurological deficits 1, 2. The vertigo must persist for more than 24 hours and be accompanied by nausea, vomiting, and gait instability 3.

Key Physical Examination Findings

• Horizontal spontaneous nystagmus with a rotational component directed toward the unaffected (healthy) ear 4
• Pathologic head-impulse test toward the affected ear—the patient's eyes make a corrective saccade when the head is rapidly turned toward the lesioned side 4, 3
• Postural imbalance with falls toward the affected ear 4
• Deviation of subjective visual vertical toward the affected ear 4
• No hearing loss, tinnitus, or aural fullness—these symptoms indicate labyrinthitis or Ménière's disease instead 1, 2
• No focal neurological deficits—dysarthria, limb weakness, sensory loss, diplopia, or Horner's syndrome suggest central pathology 5

Critical: Exclude Posterior Circulation Stroke

Approximately 25% of acute vestibular syndrome presentations are due to stroke, rising to 75% in high-risk vascular cohorts 1, 6. Even when the neurologic examination appears normal, 75–80% of posterior circulation strokes present without focal deficits 1, 6.

Red Flags Requiring Urgent MRI Brain Without Contrast

• Age >50 years with vascular risk factors (hypertension, diabetes, atrial fibrillation, prior stroke) 1
• New severe headache accompanying vertigo 1
• Severe postural instability with falling 1, 6
• Pure vertical nystagmus (up-beating or down-beating) without torsional component 1, 6
• Direction-changing nystagmus without changes in head position 6
• Baseline nystagmus present without provocative maneuvers 6
• Normal head-impulse test (suggests central cause) 1, 3
• Skew deviation on alternate cover test 1, 3
• Any additional neurological symptoms (dysarthria, dysphagia, diplopia, limb weakness) 5, 6

HINTS Examination (When Performed by Trained Practitioners)

The HINTS examination (Head Impulse, Nystagmus, Test of Skew) achieves 100% sensitivity for detecting stroke when performed by neuro-otology specialists, compared to only 46% sensitivity for early MRI 1. However, emergency physicians achieve inadequate accuracy with HINTS 1. Therefore, obtain urgent MRI for any high-risk patient regardless of HINTS results 1.

Peripheral (vestibular neuritis) pattern: abnormal head-impulse test, unidirectional horizontal-rotatory nystagmus, no skew deviation 3.

Central (stroke) pattern: normal head-impulse test, direction-changing or pure vertical nystagmus, skew deviation present 1, 3.

Imaging Decisions

• No imaging is indicated for typical vestibular neuritis in low-risk patients (<50 years, no vascular risk factors) with normal neurologic exam and peripheral HINTS pattern performed by an expert 1
• MRI brain without contrast is mandatory for high-risk patients (age >50 with vascular risk factors) even with normal neurologic examination, because 11–25% harbor posterior circulation stroke 1
• CT head has <1% diagnostic yield for isolated vertigo and misses most posterior circulation infarcts (sensitivity 10–20%) 1
• MRI with diffusion-weighted imaging is the first-line study when stroke is suspected, with 4% diagnostic yield versus <1% for CT 1

Pharmacologic Management

Symptomatic Relief (Acute Phase Only: 2–3 Days Maximum)

• Prochlorperazine 10 mg IV or orally for nausea and vomiting 7, 8
• Metoclopramide 10 mg IV as an alternative antiemetic 1
• Vestibular suppressants (meclizine 25 mg three times daily, diazepam 2–5 mg, or dimenhydrinate) for severe vertigo 8, 2

Critical: Discontinue vestibular suppressants after 2–3 days because prolonged use impedes central vestibular compensation and increases fall risk, especially in elderly patients 7, 8, 2.

Specific Drug Therapy: Corticosteroids

Initiate oral corticosteroids within 72 hours of symptom onset in otherwise healthy adults 8, 2. Corticosteroids accelerate recovery of vestibular function, achieving a 62% recovery rate within 12 months 4, 8.

Recommended regimen: Methylprednisolone 100 mg daily for 3 days, then taper over 7–10 days (or equivalent prednisone dosing) 8, 2.

Withhold steroids in patients at higher risk of complications (uncontrolled diabetes, active infection, significant cardiovascular disease) 8.

Antiviral Therapy: Not Recommended

Antiviral agents (valacyclovir, acyclovir) do not improve outcomes and should not be prescribed 8, 2, 9. Although herpes simplex virus type 1 (HSV-1) reactivation is the suspected cause—HSV-1 DNA and RNA have been detected in human vestibular ganglia 4, 9—clinical trials show no benefit from antiviral therapy 9.

Vestibular Rehabilitation Therapy

Begin early vestibular rehabilitation as soon as acute symptoms subside (typically after 2–3 days) 8, 2, 3. Early resumption of normal activity promotes central compensation 8.

Vestibular rehabilitation significantly improves gait stability compared to medication alone and is particularly beneficial for elderly patients or those with heightened fall risk 1, 8, 3.

Components of vestibular rehabilitation: habituation exercises, gaze stabilization, balance retraining, and fall prevention 1, 2.

Expected Recovery and Follow-Up

• Most patients recover well even without treatment, though recovery is incomplete in many cases 4, 8
• Recovery mechanisms include: (1) partial peripheral restoration of labyrinthine function (improved by corticosteroids), (2) somatosensory and visual substitution, and (3) central compensation (improved by vestibular exercise) 4
• Reassess within 1 month to document resolution or identify persistent symptoms requiring further evaluation 7
• Persistent symptoms after 1 month warrant repeat examination, consideration of alternative diagnoses, and possible MRI if not already performed 7

Common Diagnostic Pitfalls

• Assuming normal neurologic exam excludes stroke—75–80% of posterior circulation strokes lack focal deficits 1, 6
• Relying on HINTS examination by non-experts—emergency physicians do not achieve adequate sensitivity 1
• Missing vestibular pseudoneuritis due to acute pontomedullary brainstem lesions or cerebellar nodular infarctions 4
• Failing to distinguish from vestibular migraine—requires migraine symptoms during at least two vertiginous episodes 1, 6
• Overlooking monosymptomatic Ménière's disease—early Ménière's may present without hearing loss initially 4
• Prolonged use of vestibular suppressants—delays compensation and increases fall risk 7, 8, 2