How is vertigo managed in pregnancy?

Management of Vertigo in Pregnancy

The management of vertigo during pregnancy should prioritize non-pharmacological approaches first, with positional maneuvers like the Epley maneuver being the first-line treatment for benign paroxysmal positional vertigo (BPPV), as they are safe and effective while avoiding medication exposure to the fetus. 1

Diagnosis and Differential Considerations

• Diagnostic evaluation should distinguish between peripheral causes (inner ear) and central causes (brainstem or cerebellum) of vertigo 1
• Key diagnostic features include timing and duration of vertigo episodes, association with position changes, and presence of associated symptoms like hearing loss, tinnitus, or aural fullness 1
• Common vertigo conditions that may be exacerbated during pregnancy include Meniere's disease, vestibular migraine, and BPPV 2
• Vestibular migraine is a leading cause of vertigo in pregnancy and may present with diverse symptoms including vertigo, aura, nausea, vomiting, and tinnitus 3

Non-Pharmacological Management (First-Line)

• Positional maneuvers (Epley maneuver) should be used first for BPPV during pregnancy 1
• Lifestyle modifications to reduce symptoms include:
  • Limiting salt/sodium intake 1
  • Avoiding excessive caffeine, alcohol, and nicotine 1
  • Maintaining well-balanced meals and adequate hydration 1
  • Implementing stress management techniques 1
  • Ensuring regular exercise and adequate sleep 1
  • Identifying and managing any contributing allergies 1

Pharmacological Management (Second-Line)

• Medications should only be used when non-pharmacological approaches fail and symptoms are severe enough to warrant treatment 1
• Paracetamol (acetaminophen) is the first-line medication for symptomatic relief during pregnancy, despite its relatively poor efficacy 1
• For acute vertigo attacks requiring medication:
  • Metoclopramide can be used for associated nausea 1
  • Vestibular suppressants should be limited to short courses only during acute attacks 1
• Caution with meclizine: While indicated for vertigo associated with vestibular system diseases, the FDA label notes an increased incidence of fetal malformations in animal studies at doses similar to clinical doses 4
• Benzodiazepines carry significant risk for dependence and should be avoided during pregnancy 1

Special Considerations and Precautions

• All vestibular suppressants can delay central compensation and should be used for the shortest time possible 1
• Meclizine should be used with caution in patients with asthma, glaucoma, or enlargement of the prostate gland due to its potential anticholinergic action 4
• Drowsiness is a common side effect of meclizine, and patients should be warned against driving or operating dangerous machinery 4
• Avoid concurrent use of meclizine with alcohol or other CNS depressants due to increased risk of CNS depression 4

When to Refer to a Specialist

• Refer when vertigo is accompanied by neurological symptoms 1
• Refer when symptoms are severe and refractory to initial management 1
• Refer when there is significant hearing loss or other concerning otologic symptoms 1
• Refer when symptoms persist despite appropriate treatment 1

Monitoring and Follow-up

• Reassess within one month after initial treatment to confirm symptom resolution 1
• Monitor for medication side effects, particularly when using vestibular suppressants 1
• Adjust management based on symptom progression 1
• For patients with vestibular migraine, consider screening for associated comorbidities such as anxiety, depression, and hypertensive disorders 3

Postpartum Considerations

• Paracetamol remains the preferred medication for vertigo symptoms postpartum 1
• Ibuprofen and sumatriptan are considered safe during breastfeeding 1
• Propranolol is the recommended first choice for preventive medication in the postpartum period 1