Treatment of Vertigo During Pregnancy
For vertigo during pregnancy, meclizine 25-100 mg daily in divided doses is the recommended first-line pharmacological treatment, as it is FDA-approved specifically for vertigo associated with vestibular system diseases and has acceptable safety data in pregnancy. 1
Initial Management Approach
Non-Pharmacological Treatment (First-Line)
Before initiating any medication, attempt conservative measures:
- Vestibular rehabilitation exercises and physical therapy maneuvers, particularly for benign paroxysmal positional vertigo (BPPV), which is commonly exacerbated during pregnancy 2
- Canalith repositioning procedures (Epley maneuver) for BPPV - these are safe, effective, and should be attempted before medications 3
- Adequate hydration and regular meals 4
- Sufficient and consistent sleep patterns 4
- Identification and avoidance of triggers 4
Important caveat: Vestibular suppressant medications like antihistamines and benzodiazepines are NOT recommended as primary treatment for BPPV, as they lack evidence for definitive treatment and may interfere with central compensation 3
Pharmacological Treatment
First-Line Medication
Meclizine hydrochloride is the preferred pharmacological option:
- Dosage: 25-100 mg daily orally in divided doses, adjusted based on clinical response 1
- Safety profile: Epidemiological studies have not generally indicated a drug-associated risk of major birth defects with meclizine during pregnancy, though animal studies showed fetal malformations at clinically similar doses 1
- Administration: Tablets must be swallowed whole 1
- Precautions: Use with caution in patients with asthma, glaucoma, or prostate enlargement due to anticholinergic effects 1
Alternative Considerations Based on Etiology
For vestibular migraine-related vertigo (a leading cause of vertigo in pregnancy):
- Acute treatment: Paracetamol (acetaminophen) 1000 mg is first-line, preferably as suppository 4, 5
- Second trimester only: NSAIDs like ibuprofen can be used if paracetamol fails, but must be avoided in first and third trimesters 4, 5
- Metoclopramide for associated nausea during second and third trimesters 4, 5
- Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail 4
For prophylaxis (if vertigo is frequent and disabling):
- Propranolol has the best safety profile for preventive therapy 4, 5
- Metoprolol is also acceptable 5
- Amitriptyline if propranolol is contraindicated 4
Medications to Avoid
Absolutely contraindicated:
- Benzodiazepines (diazepam, clonazepam) - interfere with vestibular compensation and have sedative effects 3
- Ergotamine derivatives and dihydroergotamine 4, 5
- Topiramate, candesartan, sodium valproate - known adverse fetal effects 4
- Atenolol - associated with intrauterine growth retardation, especially with early and prolonged use 3
Special Considerations
Timing During Pregnancy
- First trimester: Avoid all medications when possible due to highest risk of congenital malformations 3
- Second trimester: Broader medication options available, including NSAIDs 4, 5
- Third trimester: Avoid NSAIDs and aspirin 5
Warning Signs Requiring Further Evaluation
- New headache with hypertension should be considered preeclampsia until proven otherwise 4
- Failure to respond to treatment within 1 month requires reassessment to confirm diagnosis, as 1.1-3% of presumed BPPV cases are actually CNS lesions 3
- Persistent symptoms after repositioning maneuvers may indicate incorrect diagnosis 3
Monitoring Requirements
- Regular monitoring is essential when medications are used during pregnancy, especially for preventive treatments 4
- Reassess within 1 month after initial treatment to confirm symptom resolution 3
- Multidisciplinary communication among experienced clinicians should occur throughout pregnancy, peridelivery, and postpartum 4