What is the drug of choice for treating vertigo in pregnancy?

Management of Vertigo in Pregnancy

The treatment of choice for vertigo in pregnancy is non-pharmacological management, specifically repositioning maneuvers (Epley or Semont), which should be performed first before considering any medications. 1

First-Line Approach: Non-Pharmacological Management

• Repositioning maneuvers (Epley or Semont) are the safest and most effective first-line treatment for vertigo in pregnancy, particularly for Benign Paroxysmal Positional Vertigo (BPPV) 1
• These maneuvers should be performed by healthcare providers familiar with the technique
• Additional non-pharmacological measures to implement:
  • Elevation of the head while sleeping
  • Application of ice or heat to affected areas
  • Gentle exercise programs
  • Physical therapy referral 1

Second-Line Approach: Pharmacological Management

When non-pharmacological approaches fail to provide adequate relief and symptoms are severe:

Recommended medications (for short-term use only):

• Antihistamines are the drugs of choice when medication is necessary:
  • Meclizine - lowest effective dose for shortest duration possible
  • Diphenhydramine - lowest effective dose for shortest duration possible 1

Medications to avoid:

• Benzodiazepines (diazepam, clonazepam) - can interfere with central compensation, cause potential fetal effects, and lead to dependence 1
• NSAIDs - avoid in first trimester (risk of congenital malformations) and after 28 weeks (risk of premature closure of ductus arteriosus) 1
• Oral decongestants - especially in first trimester 1

Special Considerations

For vertigo associated with migraine:

• Beta-blockers (metoprolol, propranolol) may be reasonable options due to their extensive safety record in pregnancy 1
• Verapamil may be considered when other treatments are ineffective, but carries risk of maternal hypotension 1

For pain management if needed:

• Acetaminophen is the first-line pain medication (650 mg every 6 hours or 975 mg every 8 hours, maximum 3000-4000 mg daily) 1

Monitoring and Follow-up

• Reassess within one month after initial treatment to confirm symptom resolution 1
• Discontinue medications as soon as possible to avoid interference with natural vestibular compensation 1
• Monitor for medication side effects and fetal well-being

Common Pitfalls to Avoid

1. Prolonged medication use - Extended use of vestibular suppressants can delay natural compensation and recovery 1
2. Inappropriate medication selection - Using contraindicated medications like sodium valproate, topiramate, or candesartan which have known adverse fetal effects 1
3. Failure to identify underlying cause - Different types of vertigo (BPPV, vestibular neuritis, Ménière's disease, migraine-associated) may require specific management approaches 1, 2
4. Self-medication - Over 60% of women self-report using analgesics while pregnant, often without medical guidance 1

Remember that many cases of BPPV resolve spontaneously over time, so reassurance and education about the benign nature of the condition can be valuable components of management 1.