This handout is for vestibular neuritis / acute labyrinthitis (acute vestibular syndrome, peripheral). Your care team identified this based on: acute or subacute sustained spinning vertigo lasting ≥24 h with nausea/vomiting, head-motion intolerance and gait unsteadiness — acute vestibular syndrome (avs); apply hints first, not positional testing (bárány auvp criteria, strupp j vestib res 2022; newman-toker neurol clin 2015 titrate).
Other reasons your team may use this plan: spontaneous unidirectional horizontal-torsional nystagmus, direction-fixed, suppressed by visual fixation and enhanced by frenzel/cover removal — the leading peripheral-avs sign (bárány auvp criteria, strupp j vestib res 2022; kattah stroke 2009); acute prolonged vertigo plus new unilateral sensorineural hearing loss / tinnitus / aural fullness — labyrinthitis (cochleovestibular); hints-plus positive — raises aica-stroke risk and routes to the ssnhl pathway (newman-toker aem 2013 hints-plus; saber tehrani neurology 2014); acute prolonged vertigo with any central feature (the 4 d's — diplopia, dysarthria, dysphagia, dysmetria; severe truncal/gait ataxia; direction-changing/vertical nystagmus; skew; new severe headache/neck pain) — posterior-circulation-stroke entry (kattah stroke 2009; saber tehrani neurology 2014).
Take these medications exactly as prescribed. Do not stop or change a dose without talking to your provider.
| Medication | Starting dose | How | When | What it does |
|---|---|---|---|---|
| meclizine | 25 mg | PO | q6-8h PRN (≤48-72 h ONLY) | Symptomatic acute-phase suppressant ONLY. Prolonged vestibular-suppressant use RETARDS central vestibular compensation and delays recovery — explicitly time-limited to ≤48-72 h (Strupp NEJM 2004 context; McDonnell Cochrane 2015 — rehab, not suppression, drives recovery) |
| dimenhydrinate | 50 mg | PO/IM/IV | q4-6h PRN (≤48-72 h ONLY) | Short-course antiemetic/suppressant bridge for distressing acute nausea/vomiting; same compensation-retarding caveat — discontinue by 48-72 h once acute phase settles |
| prochlorperazine | 5-10 mg | PO/IM/IV | q6-8h PRN (short course) | Parenteral antiemetic for intractable vomiting/dehydration enabling rehydration; counsel extrapyramidal/akathisia risk; avoid repeated/chronic dosing (compensation + EPS/falls in elderly) |
| ondansetron | 4-8 mg | PO/IV | q8h PRN (short course) | Antiemetic that does NOT suppress the vestibular system (no compensation penalty) — useful when an antidopaminergic/antihistamine is contraindicated or in pregnancy; counsel QT prolongation |
| diazepam | 2-5 mg | PO/IV | single / very short course only | Reserve a single low dose for extreme refractory acute distress ONLY — benzodiazepines markedly IMPAIR vestibular compensation and increase falls (especially elderly); explicitly avoid ongoing use (Strupp NEJM 2004 context) |
Plan: Vestibular neuritis — strictly short-course symptomatic suppressant (≤48-72 h) → early vestibular rehabilitation (definitive recovery lever) + debated corticosteroid
Contact your care team if any of the following happen:
Call 911 or go to the nearest emergency room right away if you have:
Reassess at ~1-4 weeks: most recover via central compensation over weeks; persistent imbalance/oscillopsia → structured vestibular rehabilitation (clinician- or home-based — McDonnell Cochrane 2015). Pursue secondary substrate: post-neuritis BPPV (utricular otoconia shed → new positional spells → route to ent.bppv.core.v1), incomplete compensation in the elderly (fall-injury risk → route to geriatrics.falls.core.v1), and audiometry follow-up if labyrinthitis. Educate on recovery trajectory, that residual unsteadiness for weeks is expected and NOT failure, and central return precautions.
Guideline: Bárány Society — Acute Unilateral Vestibulopathy / Vestibular Neuritis: Diagnostic Criteria (Strupp et al, J Vestib Res 2022, PMID 35723133) + Strupp et al, NEJM 2004 (methylprednisolone improves caloric recovery, valacyclovir ineffective; PMID 15269315) + Fishman et al, Cochrane 2011 (corticosteroids — insufficient evidence; PMID 21563170) + Leong et al, OHNS 2021 (PMID 33525978) + McDonnell & Hillier, Cochrane 2015 (vestibular rehabilitation; PMID 25581507) + HINTS (Kattah Stroke 2009 PMID 19762709; Newman-Toker AEM 2013 PMID 24127701; Saber Tehrani Neurology 2014 PMID 24920847) + TiTrATE (Newman-Toker & Edlow Neurol Clin 2015 PMID 26231273). Reconciled 2026-05-17 — PubMed-verified; the 2022 Bárány AUVP criteria are the current operational standard, no superseding guideline.