Management
Treatment & recovery
Control the misery of the first days, then get out of the brain’s way — recovery is driven by compensation, and the things that help most are movement and rehabilitation, not drugs.
What the evidence supports
Medicines for sickness and dizziness help in the first day or two, but should not be continued — they slow the brain’s recovery. Steroids are sometimes used. The best treatment is to start moving and doing balance exercises as soon as possible.
The landmark RCT showed methylprednisolone improved peripheral (caloric) recovery, while valacyclovir conferred no benefit, alone or combined.1 A later Cochrane review judged the long-term symptomatic benefit of steroids unproven — hence genuine practice variation.2
Whatever you decide about steroids, the evidence is unambiguous on two points: antivirals do not work for idiopathic neuritis, and vestibular rehabilitation is safe and effective for unilateral peripheral hypofunction.3 Keep vestibular suppressants to the first few days; beyond that they retard central compensation.4
The management plan
Three strands run in parallel rather than in strict sequence: brief symptomatic relief, selective disease-modifying treatment, and the rehabilitation that does the real work.
Acute symptomatic — first days only
- Antiemetics / vestibular suppressantsAntihistamines, prochlorperazine or a benzodiazepine to control vertigo, nausea and vomiting — for 1–3 days at most. Prolonged use blunts central compensation.
- Hydration & antiemesisRehydrate; admit if vomiting prevents oral intake. Mobilise as soon as tolerated rather than enforcing bed rest.
Disease-modifying — selective
- CorticosteroidsMethylprednisolone improved measured peripheral (caloric) recovery in an RCT; a Cochrane review judged the long-term symptomatic benefit unproven, so practice varies. Weigh comorbidities.
- Antivirals — not indicatedValacyclovir conferred no benefit, alone or added to steroid, in the randomised trial. Do not use for idiopathic neuritis.
- Treat the cause (labyrinthitis)Antibiotics and urgent ENT input for suppurative (bacterial) labyrinthitis from otitis media or meningitis; manage the underlying illness.
Recovery — the mainstay
- Vestibular rehabilitation (VRT)Graded gaze-stabilisation, habituation and balance exercises started early — the best-evidenced intervention for accelerating compensation.
- Treat sequelaeReposition a secondary BPPV; recognise and manage persistent postural-perceptual dizziness (PPPD) if symptoms outlast the deficit.
- Counsel & follow upExplain that the vHIT gain may stay reduced even as the patient feels well — recovery is compensation, and activity drives it.
The single most important message: keep vestibular suppressants brief and get the patient moving and into rehabilitation early. Recovery depends on central compensation, which inactivity and prolonged sedation hold back.
Rehabilitation — the mainstay
Vestibular rehabilitation therapy — graded gaze-stabilisation, habituation and balance work — accelerates compensation and improves outcomes; start it early rather than waiting for the acute symptoms to pass.3 The VRT chapter covers programme design and customisation in full.
Labyrinthitis & sequelae
For labyrinthitis, treat the cause in parallel: urgent antibiotics and ENT input for suppurative disease from otitis media or meningitis. On follow-up, reposition a secondary BPPV (see BPPV and the repositioning manoeuvres), and recognise persistent postural-perceptual dizziness when dizziness outlasts the deficit — it responds to rehabilitation, SSRIs and cognitive approaches rather than more vestibular suppressants.
Key points
- Vestibular suppressants/antiemetics for the first 1–3 days only — they blunt compensation thereafter.
- Methylprednisolone improved caloric recovery in an RCT; long-term symptomatic benefit is unproven, so practice varies.
- Antivirals are not beneficial for idiopathic neuritis.
- Early vestibular rehabilitation is the best-evidenced intervention for recovery.
- Treat suppurative labyrinthitis urgently; follow up for secondary BPPV and PPPD.