Vestibular neuritis treatment
›Short-term vestibular suppressants
›Meclizine 25 mg PO every 6 to 8 hours
›Use for several days only
›Longer use inhibits central compensation
›Diazepam 2 to 5 mg PO or IV for severe acute phase
›Respiratory depression risk with higher doses
›Avoid prolonged use
›Ondansetron 4 to 8 mg PO or IV for nausea
›QTc monitoring with repeated doses
›First-line antiemetic
›Corticosteroids
›Methylprednisolone taper as treatment option
›GRACE-3 2023 includes as management option
›Starting dose 100 mg daily tapered over 3 weeks
›Evidence for hearing recovery modest
›May improve initial vestibular function recovery rate
›Avoid if contraindicated (diabetes, uncontrolled hypertension)
›Vestibular rehabilitation
›Early referral accelerates central compensation
›Gaze stabilization exercises
›Balance retraining
›Avoid prolonged bed rest
›Activity promotes central compensation
›ACEP Level B recommendation for vestibular physical therapy
›Ondansetron 4 to 8 mg IV or PO
›First-line for nausea and vomiting
›Onset 30 minutes PO, faster IV
›QTc monitoring if high-dose or repeated
›May repeat at 4 to 8 hours
›Maximum 32 mg/day
›Serotonin syndrome risk with concurrent serotonergic drugs
›Prochlorperazine 10 mg IV or IM
›Alternative antiemetic with vestibular suppression
›Akathisia risk; diphenhydramine 25 mg IV may be co-administered
›Avoid in Parkinson disease
›Effective for vestibular migraine associated nausea
›Dopamine antagonist mechanism
›QTc prolongation risk
›Dimenhydrinate 50 mg PO or IV
›Antihistamine vestibular suppressant
›Sedation effect useful in acute phase
›Avoid prolonged use
Posterior circulation stroke treatment
›Stroke protocol activation
›Thrombolysis if eligible
›IV alteplase 0.9 mg/kg, maximum 90 mg
›10% as bolus, remainder over 60 minutes
›Time window
›Within 4.5 hours of symptom onset for IV thrombolysis
›Extended window for basilar artery occlusion may apply
›Endovascular therapy
›Basilar artery occlusion consider thrombectomy
›Interventional neuroradiology consultation
›Antiplatelet therapy
›TIA or minor stroke
›Dual antiplatelet therapy aspirin 81 mg plus clopidogrel 75 mg for 21 days (POINT/CHANCE protocol)
›Followed by single antiplatelet agent
›Anticoagulation for cardioembolic source
›Atrial fibrillation: DOAC initiation based on risk-benefit timing
›Early neurology involvement
Orthostatic hypotension treatment
›Acute management
›IV normal saline 500 to 1000 ml bolus if volume depleted
›Reassess orthostatic vitals after fluid resuscitation
›Oral rehydration if tolerating fluids
›Medication review
›Identify and hold offending antihypertensives or diuretics
›Blood pressure monitoring after dose adjustment
›Chronic management guidance
›Increased salt and fluid intake if no contraindication
›Target 2 to 3 L fluid per day
›10 g sodium per day
›Compression stockings
›Lower limb vasoconstriction support
›Abdominal binders for severe autonomic failure
›Fludrocortisone 0.1 mg PO daily as outpatient option
›Volume expansion mechanism
›Avoid in heart failure
Vestibular migraine treatment
›Acute attack treatment
›Triptans
›Sumatriptan 50 to 100 mg PO or 6 mg SC
›Rizatriptan 10 mg PO
›Antiemetics for nausea
›Metoclopramide 10 mg IV or PO
›Prochlorperazine 10 mg IV
›NSAIDs
›Ibuprofen 400 to 600 mg PO with meals
›Avoid if renal impairment or GI bleeding risk
›Preventive therapy (outpatient initiation)
›Beta-blockers
›Propranolol 40 to 80 mg PO twice daily
›Metoprolol 50 to 100 mg PO daily
›Topiramate 25 to 100 mg PO daily
›Titrate slowly to reduce side effects
›Cognitive side effects and kidney stone risk counseling
›Amitriptyline 10 to 50 mg PO at night
›Low-dose anticholinergic monitoring
›Avoid in elderly