How is vertigo managed in pregnancy?

Management of Vertigo During Pregnancy

The management of vertigo during pregnancy should prioritize non-pharmacological approaches first, with medication used only when necessary due to potential risks to the fetus. 1, 2, 3

Diagnosis and Differential Considerations

• Vertigo during pregnancy may be caused by several conditions including benign paroxysmal positional vertigo (BPPV), vestibular migraine, and Ménière's disease, which can all be exacerbated during pregnancy 3
• Diagnostic evaluation should distinguish between peripheral causes (inner ear) and central causes (brainstem or cerebellum) of vertigo 4
• Key diagnostic features to identify include:
  • Timing and duration of vertigo episodes (seconds for BPPV, hours for vestibular migraine, minutes to hours for Ménière's) 5
  • Association with position changes (characteristic of BPPV) 5
  • Presence of associated symptoms like hearing loss, tinnitus, or aural fullness (suggestive of Ménière's) 5
  • Concurrent headache, photophobia, or history of migraine (suggestive of vestibular migraine) 5

Non-Pharmacological Management

• Positional maneuvers should be first-line treatment for BPPV during pregnancy 5

  • Canalith repositioning procedures (Epley maneuver) are safe and effective for posterior canal BPPV 5
  • These maneuvers avoid medication exposure to the fetus 5

• Lifestyle modifications to reduce symptoms:

  • Limiting salt/sodium intake to reduce fluid retention 5
  • Avoiding excessive caffeine, alcohol, and nicotine 5
  • Maintaining well-balanced meals throughout the day 5
  • Adequate hydration with water 5
  • Stress management techniques 5
  • Regular exercise as tolerated 5
  • Adequate sleep 5
  • Identifying and managing any allergies that may contribute to symptoms 5

Pharmacological Management

• Medications should be used only when non-pharmacological approaches fail and symptoms are severe enough to warrant treatment 5

• For acute vertigo attacks requiring medication:

  • Paracetamol (acetaminophen) should be used as first-line medication for symptomatic relief during pregnancy despite its relatively poor efficacy 5
  • Metoclopramide can be used for associated nausea 5
  • Meclizine (antihistamine) should be used with caution and only for short periods due to potential anticholinergic effects 6
  • Vestibular suppressants should be limited to short courses only during acute vertigo attacks 5

• For migraine-associated vertigo:

  • NSAIDs should only be used during the second trimester if necessary 5
  • Triptans should be avoided or used only under specialist supervision with sumatriptan having the most safety data 5
  • If preventive therapy is absolutely necessary for frequent, disabling attacks, propranolol has the best safety profile, followed by amitriptyline - both should be used under specialist supervision 5
  • Topiramate, candesartan, and sodium valproate are contraindicated during pregnancy 5

Special Considerations

• Medication risks must be carefully weighed against benefits:

  • Antihistamines like meclizine may cause drowsiness and have anticholinergic effects 6
  • Benzodiazepines carry significant risk for dependence and should be avoided 5
  • All vestibular suppressants can delay central compensation and should be used for the shortest time possible 5

• Postpartum considerations:

  • Paracetamol remains the preferred medication for vertigo symptoms 5
  • Ibuprofen and sumatriptan are considered safe during breastfeeding 5
  • If preventive medication is required, propranolol is recommended as first choice 5

When to Refer

• Refer to a specialist when:
  • Vertigo is accompanied by neurological symptoms (suggesting central cause) 5
  • Symptoms are severe and refractory to initial management 5
  • There is significant hearing loss or other concerning otologic symptoms 5
  • Symptoms persist despite appropriate treatment 5

Monitoring and Follow-up

• Reassess within one month after initial treatment to confirm symptom resolution 5
• Monitor for medication side effects, particularly when using vestibular suppressants 5
• Adjust management based on symptom progression and trimester of pregnancy 3