Managing Vertigo in Pregnancy
The primary treatment for vertigo in pregnancy is the canalith repositioning procedure (Epley maneuver for posterior canal BPPV), which is safe, highly effective, and avoids medication exposure to the fetus. 1, 2
Diagnosis First: Identify the Type and Canal
Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (85-95% of cases), looking for vertigo with torsional upbeating nystagmus after a 5-20 second latency that resolves within 60 seconds. 1, 2
If Dix-Hallpike is negative but positional vertigo persists, perform the supine roll test to assess for lateral (horizontal) canal BPPV, which accounts for 10-15% of cases. 2
BPPV is more common in women and may be exacerbated by pregnancy-related hormonal changes affecting the inner ear. 3, 4
Treatment Algorithm by Canal Type
For Posterior Canal BPPV (Most Common)
Perform the Epley maneuver immediately - this provides 70-80% resolution within 48 hours after a single treatment, with success rates reaching 90-98% after repeat maneuvers if needed. 1, 2, 5
Epley maneuver technique: 1
- Patient sits upright with head turned 45° toward affected ear
- Rapidly lay patient back to supine head-hanging position (20° extension) for 20-30 seconds
- Turn head 90° toward unaffected side, hold 20-30 seconds
- Continue rotating head another 90° (patient moves to lateral decubitus, face nearly down), hold 20-30 seconds
- Return patient to upright sitting position
Alternative: Semont (liberatory) maneuver - equally effective with 94% resolution at 6 months, though requires more rapid movements. 1, 2, 6
For Lateral Canal BPPV
For geotropic variant: Use Gufoni maneuver (93% success) or barbecue roll maneuver (75-90% effectiveness). 1, 2
For apogeotropic variant: Use modified Gufoni maneuver (patient lies on affected side). 1, 2
Critical Management Principles in Pregnancy
Do NOT prescribe vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) as primary treatment - they have no evidence of effectiveness for BPPV, interfere with central compensation, and expose the fetus to unnecessary medications. 2, 7
Antiemetics may be considered only for severe nausea/vomiting during the maneuver itself, given 30-60 minutes before the procedure. 1
No postprocedural restrictions are needed - patients can resume normal activities immediately after treatment, as restrictions provide no benefit and may cause unnecessary complications. 2
When Treatment Fails
If symptoms persist after initial treatment: 2
- Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV
- Perform additional repositioning maneuvers (success rates reach 90-98% with repeat treatments)
- Check for canal conversion (occurs in 6-7% of cases during treatment)
- Evaluate for multiple canal involvement or bilateral BPPV
- Rule out coexisting vestibular pathology if symptoms occur with general head movements or spontaneously
Self-Treatment Option
Teach motivated patients self-administered Epley maneuver after at least one properly performed in-office treatment - this achieves 64% improvement compared to 23% with Brandt-Daroff exercises. 2
Safety Considerations Specific to Pregnancy
The Epley and other repositioning maneuvers are mechanical treatments that pose no risk to the fetus and avoid medication exposure. 1, 2
Assess for physical limitations before performing maneuvers, including severe cervical issues, though pregnancy itself is not a contraindication. 2
Common adverse effects during maneuvers include transient nausea, occasional vomiting, and sense of falling - these are self-limiting and do not contraindicate treatment. 1
Common Pitfalls to Avoid
Do not delay treatment - 70% of patients achieve resolution within 48 hours of the first Epley maneuver, providing immediate relief without medication. 5
Do not confuse residual lightheadedness (occurs in 47% of cases) with persistent vertigo - true BPPV vertigo is brief, positional, and spinning in nature. 5
Do not order imaging or vestibular testing unless the diagnosis is uncertain or atypical features suggest central pathology. 2
Do not impose bed rest or activity restrictions after successful treatment - this provides no benefit and may worsen deconditioning. 2