There’s definitely something about head tilt in rabbits that sets off immediate panic. Seeing your rabbit going about his daily business one minute and suffering from head tilt the next, that is scary stuff. He's snacking on some hay, tossing around a chew, digging where he shouldn't, and then BAM... he's off balance and walking in circles. It's understandably distressing for you both.
What happened? Is he in pain? Will he recover?
We often immediately think stroke when a rabbit develops head tilt. While a stroke is possible, take a moment before jumping to any conclusions. Ear infections and a parasite called Encephalitozoon cuniculi are more common causes of head tilt in rabbits. Luckily, both can be treated.
Head Tilt Caused by Ear Infections
Ear infections can cause sudden head tilt in rabbits. This happens when bacteria spreads from the nasal cavity through the Eustachian tube into the middle/inner ear. Middle ear infections can come from an upper respiratory infection. Inner ear infections can come from an outer ear infection that isn't treated promptly. See a pattern? Rabbits like to hide illness, so by the time we catch on, we're dealing with a whole new problem.
Signs of an outer ear infection may be subtle, which is why they easily go unnoticed. You may see some shaking of or scratching at the ears. Maybe they just doesn't seem to be acting like them self. Trust your gut. As the infection moves to the middle ear, the ear itself may begin to droop. Rabbits can also form a super thick pus which can cause hearing loss. (He's not just ignoring you.)
In addition to head tilt, a worsening inner ear infection can cause loss of balance, circling, and rolling. Your rabbit's eyes may move up and down involuntarily and inflammation can cause facial paralysis. By this point, your rabbit will likely start showing signs of discomfort and possibly start to refuse food.
The first thing to do, of course, is to get to a rabbit-savvy vet ASAP for a proper diagnosis. Causes of head tilt in rabbits are all treated differently, so knowing the reason is absolutely essential. The vet may take a blood sample, do X-rays, and culture pus inside the ear. If an ear infection is confirmed, your rabbit may be prescribed anti-vertigo medication and anti-inflammatory medication in addition to antibiotics and possibly steroids. Because rabbits form such thick pus, drains are not effective in most cases, but sometimes surgery is warranted. Because an ear infection can be stubborn, be prepared for a course of antibiotics that lasts several weeks and possibly even months. With time and patience (and a little less sleep than you’re probably used to), your rabbit can make a full recovery.
Head Tilt Caused by E. Cuniculi
You might be saying my rabbit doesn't go outside, or play with other rabbits, so how could he encounter a parasite? E. cuniculi should never be ruled out for this reason. The parasite is most often transmitted from oral ingestion of spores found in urine. But it can also come through the placenta when a rabbit is born from an infected mama bun. It can go unnoticed for years. Seemingly randomly, symptoms (like head tilt) may appear during illness, injury, or stress. Many rabbits live totally normal, symptom-free lives with the protozoan parasite. In an unfortunate few, however, it goes after the brain and spinal cord and causes chronic inflammation.
A blood test at your vet will check for IgG and IgM antibodies. This reveals if the rabbit has been exposed. Even if the testing is inconclusive, they may recommend a 28-day course of medication based on symptoms alone. An oral wormer like fenbendazole will stop the parasite from shedding. E. cuniculi can't technically be "cured" the same way an ear infection can with antibiotics. However, treatment can stop head tilt in rabbits from getting worse and reduce, or even eliminate, clinical signs.
The Road to Recovery
Your rabbit may get worse before they get better. This can be distressing, but please know it isn't abnormal. Vertigo isn't fun for either of you, so you'll want to keep the environment as calm and quiet as possible while they recover. Try not to handle your rabbit too much, it's unpleasant for them not to have their feet on the ground when balance is a challenge.
Don't feel guilty about confining your house rabbit to a smaller space. Because they’re having trouble with balance, they’ll appreciate familiar surroundings for now. A laundry basket works well during rolling episodes. Rolled towels can create "bumpers" to keep them from falling over until they regain balance (and confidence). Once your rabbit starts to improve, you can slowly introduce them to more and more space. Exercise can even be beneficial once on the road to recovery.
Your rabbit may need to be syringe fed at first. If there's a time for a treat of alfalfa, this is it. When they’re eating on their own again, you still may need to modify food and water dishes for easy access. Low-entry litter boxes will be appreciated too. Much easier to hop in and out of when your head is a little out of place!
While head tilt in rabbits is scary, many of the common causes can be remedied. That being said, treatment isn't always easy or 100% successful, and it can be a challenging journey for both you and your rabbit. It always helps to be prepared. Don't lose hope. Even if your rabbit always has a slight head tilt, they may adapt better than you think.
Even though ear infections and E. cuniculi are behind many cases of head tilt, always consult your exotic vet to rule out other possibilities. Anything from toxins, stroke, trauma or injury, cancer and brain tumors, even mites and other parasitic infestations can cause head tilt and similar symptoms. Some rabbits, those that should NOT be buying lottery tickets, can even be impacted by two conditions at once (i.e. ear mites causing a secondary bacterial infection). Whatever the cause, be patient and know that there is hope. Your rabbit may surprise you with a full recovery like Bella! Check out her story below. ⬇️