What are the recommended management options for vertigo in pregnancy?

Management of Vertigo in Pregnancy

The canalith repositioning procedure (Epley maneuver) is the primary treatment for vertigo in pregnancy, as it is safe, highly effective (70-80% resolution after single treatment, 90-98% with repeat maneuvers), and completely avoids medication exposure to the fetus. 1

Diagnostic Approach

Identify the type and canal involved:

• Perform the Dix-Hallpike maneuver to diagnose posterior canal BPPV (accounts for 85-95% of cases), looking for torsional upbeating nystagmus with 5-20 second latency that resolves within 60 seconds 2, 1
• If Dix-Hallpike is negative but BPPV suspected, perform the supine roll test to assess for lateral canal BPPV (10-15% of cases) 2, 1
• 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

Posterior Canal BPPV (85-95% of cases)

Primary treatment: Epley maneuver 1, 5

• Success rate: 70-80% resolution within 48 hours after single treatment 1
• With repeat maneuvers: 90-98% success rate 1, 5
• Alternative: Semont (liberatory) maneuver - equally effective with 94% resolution at 6 months 1, 6

Lateral (Horizontal) Canal BPPV (10-15% of cases)

For geotropic variant:

• Gufoni maneuver (93% success rate) - preferred as easier to perform 1, 5
• Barbecue roll maneuver (75-90% effectiveness) - alternative option 1, 5

For apogeotropic variant:

• Modified Gufoni maneuver (patient lies on affected side) 5

Critical Medication Management in Pregnancy

Vestibular suppressant medications (meclizine, antihistamines, benzodiazepines) should NOT be prescribed as primary treatment for BPPV in pregnancy. 1, 5

Rationale:

• No evidence of effectiveness for BPPV treatment 2, 5
• Unnecessary fetal medication exposure 1
• Side effects include drowsiness, cognitive deficits, and increased fall risk 5, 7
• Interfere with natural vestibular compensation mechanisms 7

Limited exception: Antiemetics may be considered only for severe nausea/vomiting during the maneuver itself, given 30-60 minutes before the procedure 1

Post-Treatment Instructions

No postprocedural restrictions are needed - patients can resume normal activities immediately after treatment, as restrictions provide no benefit and may cause unnecessary complications 2, 1, 5

Safety Considerations Specific to Pregnancy

• The Epley and other repositioning maneuvers are purely mechanical treatments that pose no risk to the fetus 1
• Pregnancy itself is not a contraindication to performing these maneuvers 1
• Assess for severe cervical spine issues before performing maneuvers, though these are rare contraindications 1, 5
• Common transient effects during maneuvers include nausea, occasional vomiting, and sense of falling - these are self-limiting and do not contraindicate treatment 1

Management of Treatment Failures

If symptoms persist after initial treatment (reassess within 1 month): 2, 5

• Repeat the diagnostic test (Dix-Hallpike or supine roll) to confirm persistent BPPV 5
• Perform additional repositioning maneuvers - success rates reach 90-98% with repeat treatments 1, 5
• Check for canal conversion (occurs in 6-7% of cases) - posterior canal may convert to lateral canal or vice versa 1, 5
• Evaluate for multiple canal involvement or bilateral BPPV 5
• Consider coexisting vestibular pathology if symptoms occur with general head movements or spontaneously 5
• Rule out central causes if atypical features present 5

Self-Treatment Option

Self-administered Epley maneuver can be taught to motivated pregnant patients after at least one properly performed in-office treatment, with 64% improvement rate (significantly more effective than Brandt-Daroff exercises at 23%) 1, 5

Common Pitfalls to Avoid

• Do not order imaging or vestibular testing unless additional symptoms inconsistent with BPPV are present 2, 5
• Do not prescribe meclizine or other vestibular suppressants as they are ineffective for BPPV and expose the fetus unnecessarily 1, 8, 9
• Do not impose postprocedural restrictions (head elevation, sleep position restrictions) as these have no benefit 2, 1
• Ensure maneuvers are performed quickly enough during execution to maximize effectiveness 5