How is vestibular migraine managed in pregnancy?

Managing Vestibular Migraine in Pregnancy

For vestibular migraine in pregnancy, start with paracetamol (acetaminophen) 1000 mg as first-line acute treatment, reserve NSAIDs for second trimester only, and use propranolol for prophylaxis only if attacks are frequent and disabling enough to warrant the fetal monitoring risks. 1, 2

Acute Treatment Algorithm

First-Line Therapy

• Paracetamol (acetaminophen) 1000 mg should be used as the initial acute treatment, despite its relatively poor efficacy, because it has the best safety profile throughout all trimesters of pregnancy. 1, 2

Second-Line Options

• NSAIDs (ibuprofen, naproxen) can be used ONLY during the second trimester as second-line therapy when paracetamol fails. 1, 2
• NSAIDs must be avoided in the first trimester (risk of congenital malformations) and third trimester (risk of premature closure of ductus arteriosus, oligohydramnios, and bleeding complications). 2, 3

Specialist-Supervised Options

• Sumatriptan may be used sporadically under strict specialist supervision when other treatments fail, as it has the most safety data among triptans from post-marketing surveillance. 1, 2
• Triptans should only be considered for severe, disabling attacks that don't respond to safer alternatives. 1

Symptomatic Treatment

• Metoclopramide can be used for nausea and vomiting associated with vestibular migraine, particularly during the second and third trimesters. 1, 2
• For vertigo symptoms specifically, dimenhydrinate may be considered as an antiemetic and anti-vertigo agent. 4

Prophylactic Treatment Approach

When to Consider Prophylaxis

• Preventive medications should be avoided during pregnancy unless absolutely necessary for frequent and disabling attacks that significantly impact quality of life. 1, 2
• The decision to use prophylaxis requires weighing the risk of fetal harm against the maternal morbidity from uncontrolled vestibular migraine. 1

First-Line Prophylaxis

• Propranolol (80-160 mg daily in long-acting formulations) has the best safety data and should be the first choice if prophylaxis is deemed clinically necessary. 1, 2
• Propranolol requires specialist supervision with regular fetal monitoring, as beta-blockers have been associated with intrauterine growth retardation, though this risk appears less pronounced than with atenolol. 1

Second-Line Prophylaxis

• Amitriptyline (10-100 mg at night) can be considered if propranolol is contraindicated (e.g., asthma, cardiac failure, Raynaud disease, atrioventricular block). 1
• Amitriptyline also requires specialist supervision and fetal monitoring. 1

Absolutely Contraindicated Medications

• Sodium valproate is absolutely contraindicated due to known teratogenicity and must never be used in women of childbearing potential. 1
• Topiramate is contraindicated due to adverse fetal effects including increased risk of oral clefts. 1, 2
• Candesartan is contraindicated due to adverse effects on fetal development. 1

Non-Pharmacological Management (Essential First-Line)

Before initiating any pharmacological treatment, non-pharmacological approaches must be tried first and should complement any required drug therapy. 2, 3

Lifestyle Modifications

• Maintain adequate hydration and regular meal schedules to prevent migraine triggers. 2
• Secure sufficient and consistent sleep patterns (7-9 hours nightly). 2
• Engage in appropriate physical activity as tolerated, which can reduce migraine frequency. 2
• Identify and avoid specific vestibular migraine triggers including dietary triggers (caffeine, aged cheese, alcohol), environmental triggers (bright lights, strong odors), and stress. 5, 4

Vestibular Rehabilitation

• Vestibular rehabilitation therapy should be considered for all patients with vestibular migraine, as it can improve balance function and reduce symptom severity without medication risks. 4

Critical Clinical Considerations

Diagnostic Vigilance

• Any new headache in a pregnant woman with hypertension must be considered part of preeclampsia until proven otherwise, as this represents a life-threatening condition requiring immediate evaluation. 2
• Vestibular migraine is likely underdiagnosed in pregnancy because symptoms like nausea, vomiting, and dizziness may be attributed to normal pregnancy changes. 5

Timing of Medication Use

• If possible, all medications should be avoided during the first trimester when the risk of congenital malformations is greatest. 1
• Use the lowest effective dose with regular monitoring of clinical response. 1

Medication Overuse Risk

• Monitor for medication overuse headache, which can occur with frequent use of acute medications (≥15 days/month with NSAIDs or paracetamol; ≥10 days/month with triptans). 2

Associated Comorbidities

• Screen for and treat neuropsychiatric comorbidities including anxiety and depression, which are closely associated with vestibular migraine and contribute to maternal morbidity. 5
• Monitor for hypertensive disorders and cardiovascular disease, as these are important contributors to pregnancy-related morbidity and mortality in migraine patients. 5

Postpartum Management

Acute Treatment

• Paracetamol remains the preferred acute medication during breastfeeding. 1, 2
• Ibuprofen and sumatriptan are considered safe during breastfeeding and can be used as needed. 1, 2

Prophylaxis

• Propranolol is the recommended first choice for preventive therapy postpartum due to its best safety profile during breastfeeding. 1, 2

Expected Course

• Migraine symptoms typically recur shortly after delivery as estrogen levels drop precipitously, so anticipatory counseling and treatment planning should occur before discharge. 3, 6