Vertigo: Vestibular Neuritis

Clinical Scenario

Rachel Green, 42, a secondary school headteacher, calls in acute distress. She woke this morning with severe rotational vertigo, nausea, and vomiting. The room is spinning constantly, not just with head movement. She cannot stand without falling to the right and has vomited four times. She has no hearing loss, no tinnitus, no headache, no limb weakness, and no speech or visual disturbance. She had a mild upper respiratory tract infection last week. She is terrified she is having a stroke and wants an ambulance.

What This Case Tests

Differentiating peripheral vestibular causes from central causes of acute vertigo; conducting a focused neurological assessment to exclude stroke or posterior fossa pathology; recognising the pattern of vestibular neuritis including the preceding viral illness; managing the patient's fear of stroke with confident reassurance; prescribing appropriate vestibular sedatives for the acute phase; advising on vestibular rehabilitation and recovery timeline

Common Mistakes Trainees Make

The three most common mistakes are: calling an ambulance or referring to A&E without first conducting a focused assessment — if the history clearly indicates peripheral vertigo with no central features, emergency referral is not necessary and subjects the patient to an unnecessary and distressing hospital visit; dismissing the severity of the symptoms because vertigo is 'benign,' when acute vestibular neuritis is genuinely debilitating and frightening; and prescribing vestibular sedatives for too long — they should only be used for the acute phase (48-72 hours) as prolonged use delays vestibular compensation.

The Consultation Challenge

Rachel is terrified she is having a stroke. This is a reasonable fear — acute vertigo with vomiting and inability to stand is alarming. Your first job is to assess safety, then reassure.

Conduct a focused neurological screen. The critical distinction is peripheral versus central vertigo. Ask specifically about the HINTS that suggest central pathology: headache (especially sudden or severe), diplopia or visual disturbance, dysarthria, dysphagia, facial weakness or numbness, limb weakness or incoordination, and new hearing loss. The absence of all of these is strongly reassuring against a central cause.

Identify the peripheral pattern: constant rotational vertigo (the room spins in one direction), worse with head movement but present at rest, associated nausea and vomiting, falling or veering to one side (the affected side), and a preceding viral illness. This is classic vestibular neuritis — post-viral inflammation of the vestibular nerve.

Reassure her directly: 'Rachel, I understand why you are frightened — this feels awful and the symptoms are dramatic. But I have asked you specifically about every stroke warning sign, and you have none of them. What this pattern tells me is that you have vestibular neuritis — an inflammation of the balance nerve in your ear, almost certainly triggered by the cold you had last week. It is not a stroke, and it is not dangerous, but it is genuinely horrible and I want to help you through it.'

Prescribe for the acute phase: prochlorperazine (Buccastal) 3mg buccal tablets — these dissolve between the gum and cheek so she does not need to swallow with the vomiting. Alternatively, prochlorperazine 12.5mg IM if she has someone who can bring her to the surgery. Cyclizine 50mg is an alternative. Critically, limit vestibular sedatives to 48-72 hours maximum — explain that after the acute phase, the brain needs to recalibrate and the medication prevents this.

Advise on the recovery timeline: the severe phase lasts 2-5 days, then gradually improves over 2-6 weeks. She will feel unsteady and off-balance during recovery — this is normal vestibular compensation. Once the acute vomiting settles, she should start gentle head movements (Cawthorne-Cooksey exercises) to promote compensation. She will likely need 1-2 weeks off work.

Safety-net clearly: if she develops any new neurological symptoms — headache, speech problems, facial weakness, limb weakness, or new hearing loss — she should call 999 immediately. Arrange a follow-up in 1 week.

Time check: Minutes 1-4 on focused neurological screen to exclude central causes. Minutes 4-7 on explaining vestibular neuritis, reassuring about stroke, and managing her fear. Minutes 7-10 on prescribing, recovery timeline, and vestibular rehabilitation advice. Final 2 minutes on safety-netting, fit note, and follow-up.

How Examiners Mark This Case

Data Gathering and Diagnosis: Examiners assess whether you systematically screen for central causes — specifically asking about the key posterior circulation stroke features: headache, diplopia, dysarthria, dysphagia, facial symptoms, and limb weakness. Identifying the post-viral onset as pointing to vestibular neuritis demonstrates pattern recognition. The distinction between peripheral and central vertigo is the core clinical reasoning task.

Clinical Management and Medical Complexity: Examiners evaluate whether you prescribe appropriate vestibular sedatives, specify the buccal or IM route given the vomiting, and critically limit the duration to 48-72 hours with clear explanation. Advising on vestibular rehabilitation exercises for the recovery phase and providing a realistic timeline shows comprehensive management. A fit note for 1-2 weeks demonstrates practical awareness.

Relating to Others: Examiners look for how you manage her acute fear of stroke. Taking the fear seriously, conducting a thorough assessment, and then providing confident reassurance based on the evidence is the expected approach. Simply saying 'it's not a stroke' without explaining why you are confident will not reassure an intelligent, frightened patient. Explaining the positive evidence for vestibular neuritis (preceding viral illness, peripheral pattern, no central features) is more reassuring than a list of negatives.

Example Opening

Strong opening: "Hello Rachel, I can hear how distressing this is. I want to help you, and the first thing I need to do is ask you some very specific questions to make sure this is not anything dangerous. Can you bear with me for a few minutes?"

When reassuring about stroke: "I have now asked you about every warning sign of a stroke, and you have none of them — no headache, no speech problems, no weakness, no visual changes. What you do have is a pattern that fits perfectly with something called vestibular neuritis — an inflammation of the balance nerve triggered by the cold you had last week. It is horrible, but it is not dangerous and it will get better."

Avoid: "Don't worry, it's just vertigo" — this minimises a genuinely debilitating experience and does not address her stroke fear with any clinical reasoning.

How This Appears in the SCA

Acute vertigo tests your ability to differentiate peripheral from central causes under pressure, manage a frightened patient who believes they are having a stroke, and prescribe appropriately for the acute phase. Examiners value systematic neurological screening followed by confident diagnosis and clear management.

Key Statistic

Vestibular neuritis is the second most common cause of peripheral vertigo after BPPV. It most commonly follows a viral upper respiratory tract infection by 1-2 weeks and has an annual incidence of approximately 3.5 per 100,000 population.

Relevant Guidelines

• NICE CKS: Vestibular neuritis
• NICE CKS: Vertigo — differential diagnosis
• NICE NG128: Stroke and TIA (for central cause exclusion)
• Cochrane review on vestibular rehabilitation exercises.

Frequently Asked Questions

How do I differentiate peripheral from central vertigo in primary care?

Peripheral vertigo (vestibular neuritis, BPPV, Meniere's) typically presents with: rotational vertigo (the room spins), associated nausea and vomiting, worse with head movement, falling towards the affected side, and no neurological signs. Central vertigo (posterior circulation stroke, cerebellar pathology) presents with: vertigo that may be less intense but has accompanying neurological features — new headache, diplopia, dysarthria, dysphagia, facial weakness or numbness, limb ataxia, or new hearing loss. The presence of any central feature mandates urgent assessment. In the SCA, demonstrating this systematic approach is essential.

Why should vestibular sedatives be limited to 48-72 hours?

After vestibular nerve damage, the brain undergoes central compensation — it learns to rebalance using the healthy vestibular nerve and visual and proprioceptive inputs. Vestibular sedatives (prochlorperazine, cyclizine, cinnarizine) suppress the vestibular system, which provides symptom relief in the acute phase but delays this compensation if used for longer. After 48-72 hours, the patient should stop sedatives and begin gentle head movements to promote compensation. Explain this to the patient: 'The medication is for the worst 2-3 days. After that, your brain needs to recalibrate, and the medication actually slows that process down.'

What vestibular rehabilitation exercises should I recommend?

Cawthorne-Cooksey exercises are the standard vestibular rehabilitation programme. They start simply and progress in difficulty: eye movements (looking up and down, side to side) while keeping the head still, then head movements (turning, tilting, bending) with eyes open then closed, then sitting to standing exercises, and finally walking with turns. Start once the acute vomiting has settled (usually day 3-5). Exercises should provoke mild dizziness — this is the stimulus that drives compensation. Advise doing them 3-4 times daily for 10 minutes. Most patients see significant improvement within 2-6 weeks.

When should I refer a patient with acute vertigo to hospital?

Refer urgently if any central features are present: sudden severe headache, diplopia, dysarthria, dysphagia, facial weakness, limb weakness or incoordination, or acute hearing loss (which may indicate labyrinthine infarction). Also refer if the patient is unable to tolerate any oral fluids due to persistent vomiting (risk of dehydration), if the diagnosis is uncertain, or if symptoms are not following the expected trajectory of improvement after 1 week. A young patient with acute vertigo and no central features does not routinely need hospital assessment.

How long will recovery take and when can the patient return to work?

The acute severe phase of vestibular neuritis typically lasts 2-5 days, with gradual improvement over the following 2-6 weeks. Most patients feel significantly better by 2 weeks and are functionally recovered by 6 weeks, though some residual unsteadiness with quick head movements may persist for months. For a headteacher like Rachel, 1-2 weeks off work is typical. She can return when she can walk steadily and concentrate without nausea. Driving should only resume when she can perform an emergency stop safely — advise checking with her insurer.