Management of Vestibular Neuritis

Pharmacologic Therapy

Prednisone (or prednisolone) for 10 days is the standard systemic corticosteroid regimen for acute vestibular neuritis; it improves complete caloric recovery (relative risk 2.81, 95 % CI 1.32–6.00) and the number needed to treat is 7 (95 % CI 5–18) for vestibular function restoration. Evidence is of low certainty because of small, heterogeneous trials. 1
Systemic corticosteroids increase the risk of adverse events (odds ratio 10.9, 95 % CI 1.3–93.8); the number needed to harm is 4. Most adverse effects are mild but must be weighed against benefits. Evidence quality is low. 1

Routine use of vestibular suppressors is not recommended in peripheral vestibular disorders because they impair central compensation and provide no definitive therapeutic benefit. [2][3][4][5]
These agents markedly increase the risk of falls, especially in older adults, and cause somnolence, cognitive deficits, and impaired driving. Evidence is moderate. 2
A short‑course (≤ 2–3 days) of a suppressor may be used only for severe vegetative symptoms (e.g., intractable nausea/vomiting) when other options are refused or as prophylaxis before vestibular maneuvers. This exception is weakly recommended. [2][3]

Early vestibular rehabilitation (initiated within the first week after diagnosis) significantly reduces perceived dizziness at 3 months (p = 0.007) and 12 months (p = 0.001), and improves anxiety/depression scores (HADS) and Dizziness Handicap Inventory (DHI) at 12 months (p ≈ 0.04–0.05). Evidence is moderate to high. 6
Combining vestibular rehabilitation with corticosteroids yields superior outcomes compared with steroids alone, including greater improvement in DHI (‑14.86 at 1 month, ‑4.63 at 3 months, ‑9.50 at 1 year) and better caloric lateralization (‑10.28 at 1 month, ‑8.12 at 3 months). Vestibular‑evoked myogenic potentials also improve. Evidence is moderate. 1
Rehabilitation protocol should include graded vestibular habituation exercises (eye, head, and trunk movements), supervised sessions (group or individual) tailored to each patient, and a home‑exercise program. The program is safe, with no serious adverse events reported in clinical trials. Evidence is high. [1][6]

Acute phase (first 10 days) – Start prednisolone 10 days and initiate supervised vestibular rehabilitation immediately after confirming the diagnosis. Avoid vestibular suppressors except for a brief course (≤ 2–3 days) in patients with severe nausea/vomiting. [2][3]
Sub‑acute / chronic phase (after day 10) – Continue vestibular rehabilitation with home exercises; reassess at 1 month to document symptom resolution or persistence. If symptoms persist, intensify individualized rehabilitation. Evidence for the 1‑month reassessment is moderate. 2

If no improvement is observed by 1 month, consider alternative central causes; 1.1–3 % of cases initially labeled “vestibular neuritis” are later identified as central nervous system lesions. [6][5]
A positive HINTS exam or abnormal neurological findings should prompt evaluation for posterior‑circulation stroke. 7
Specific comorbidities may contraindicate standard vestibular rehabilitation and require adapted protocols, including cervical stenosis, severe rheumatoid arthritis, Down syndrome, cervical radiculopathy, Paget disease, morbid obesity, ankylosing spondylitis, low‑lumbar dysfunction, and spinal cord injury. Evidence is low but based on expert consensus. [8][1]