What is the recommended treatment for vertigo in pregnancy?

Treatment of Vertigo in Pregnancy

For vertigo during pregnancy, positional maneuvers (specifically the Epley maneuver for BPPV) should be first-line treatment, avoiding medications whenever possible; when pharmacological treatment is absolutely necessary for severe symptoms, use short courses of meclizine or dimenhydrinate for acute symptom relief, with metoclopramide for associated nausea. 1, 2

Diagnostic Approach

Determine the specific type of vertigo before initiating treatment:

• BPPV characteristics: Brief episodes (seconds to minutes) triggered by specific head position changes, no hearing loss or tinnitus 1
• Vestibular migraine features: Vertigo with concurrent headache, photophobia, or prior migraine history 1
• Meniere's disease indicators: Vertigo with hearing loss, tinnitus, or aural fullness 1
• Red flags requiring urgent evaluation: Neurological symptoms, severe persistent symptoms, or significant hearing loss 1

Non-Pharmacological Management (First-Line)

Positional maneuvers are the safest and most effective treatment for BPPV in pregnancy:

• Epley maneuver should be performed for posterior canal BPPV, which is effective and avoids fetal medication exposure 1, 3
• Repositioning maneuvers demonstrate 4.1 times greater symptom resolution compared to observation within 1 month 3
• These maneuvers carry no risk to the fetus and should always be attempted before medications 1

Lifestyle modifications to reduce vertigo symptoms:

• Limit sodium intake to 1500-2300 mg daily 1
• Avoid excessive caffeine, alcohol, and nicotine 1
• Maintain adequate hydration with water and regular, well-balanced meals 1
• Ensure consistent sleep patterns and stress management 1
• Regular appropriate exercise 1

Pharmacological Management (When Non-Pharmacological Fails)

Medications should only be used when non-pharmacological approaches fail and symptoms are severe enough to warrant treatment. 1

For Acute Vertigo Attacks:

Antihistamines (safest vestibular suppressants in pregnancy):

• Meclizine is considered relatively safe and can be used for acute symptom relief 2, 4
• Dimenhydrinate is an acceptable alternative antihistamine 2
• Critical limitation: Use only for short courses during acute attacks, as prolonged use interferes with central vestibular compensation 3, 1
• Dosing per FDA label: 25-100 mg daily in divided doses depending on response 4

For associated nausea:

• Metoclopramide can be used for nausea associated with vertigo attacks 1, 3
• Vitamin B6 and ginger rhizome are alternative antiemetic options 2

Medications to Avoid:

Benzodiazepines (diazepam, clonazepam) should be avoided:

• Carry significant risk for dependence 1
• Interfere with central compensation in peripheral vestibular conditions 3
• Should only be considered in severe Meniere's disease under specialist supervision 2

Other contraindicated medications:

• Betahistine is contraindicated in pregnancy 2
• Vasodilating agents are contraindicated 2
• Selective COX-2 inhibitors are contraindicated 2

Special Considerations

Medication risks must be carefully balanced:

• All vestibular suppressants delay central compensation and should be used for the shortest time possible 1, 3
• Meclizine FDA data shows increased fetal malformations in animal studies at clinically similar doses, though human epidemiological studies have not generally indicated increased risk 4
• The estimated background risk of major birth defects in the U.S. general population is 2-4% 4

For severe, refractory cases:

• Low-dose diazepam may be considered in severe Meniere's disease with extreme caution 2
• Diuretics can be used cautiously in severe Meniere's disease 2
• Systemic prednisone or prednisolone may be considered in highly selected cases under specialist supervision 2

When to Refer to Specialist

Immediate referral indicated for:

• Vertigo accompanied by neurological symptoms 1
• Severe symptoms refractory to initial management 1
• Significant hearing loss or concerning otologic symptoms 1
• Symptoms persisting despite appropriate treatment 1

Follow-Up and Monitoring

Reassess within one month after initial treatment:

• Confirm symptom resolution 1, 3
• Monitor for medication side effects if vestibular suppressants were used 1
• Adjust management based on symptom progression 1
• Failure to respond may indicate misdiagnosis; 1.1-3% of presumed BPPV cases are actually CNS lesions 3

Postpartum Management

Medication safety during breastfeeding:

• Paracetamol remains the preferred medication for vertigo symptoms 1
• Ibuprofen is safe during breastfeeding 1
• Propranolol is the recommended first choice if preventive medication is required 1

Common Pitfalls to Avoid

• Do not use vestibular suppressants as primary treatment for BPPV - they are ineffective as definitive treatment and no substitute for repositioning maneuvers 3
• Avoid prolonged vestibular suppressant use - interferes with natural compensation mechanisms and prolongs recovery 3, 1
• Do not assume spontaneous resolution is adequate - repositioning maneuvers provide faster resolution (mean 39 days for untreated BPPV) and lower recurrence rates 3