Vestibular Sedatives in Pregnancy
Primary Recommendation
Vestibular sedatives (antihistamines and benzodiazepines) are NOT recommended as primary treatment for vertigo in pregnancy; instead, use canalith repositioning procedures (Epley maneuver) as first-line therapy for BPPV, which is safe, effective, and avoids medication exposure entirely. 1
Treatment Algorithm for Vertigo in Pregnancy
First-Line: Non-Pharmacological Approaches
Perform canalith repositioning procedures (Epley maneuver) before considering any medications, as recommended by the American Academy of Otolaryngology-Head and Neck Surgery for benign paroxysmal positional vertigo (BPPV). 1
Implement conservative measures including adequate hydration, regular meals, consistent sleep patterns, and trigger avoidance as foundational management. 1
When Pharmacological Treatment Is Necessary
Antiemetics for Acute Vertigo Attacks
Meclizine and dimenhydrinate are acceptable antiemetic options for acute vertigo episodes when non-pharmacological measures fail. 2
Metoclopramide is probably acceptable during the second and third trimester for nausea associated with vertigo. 3
Vitamin B6 and ginger rhizome serve as alternative antiemetic options with favorable safety profiles. 2
Antihistamines (Use With Caution)
First-generation antihistamines are considered relatively safe but have significant sedative properties that may interfere with vestibular compensation. 2, 4
Cetirizine (third trimester only) or loratadine (second and third trimester) from second-generation antihistamines have better safety profiles when antihistamine therapy is deemed necessary. 2, 5
Medications to AVOID
Absolutely Contraindicated
Benzodiazepines (diazepam, clonazepam) are absolutely contraindicated due to interference with vestibular compensation and sedative effects, per American Academy of Otolaryngology-Head and Neck Surgery guidelines. 1
Betahistine and vasodilating agents are contraindicated in pregnancy. 2
Atenolol should never be used due to well-documented association with intrauterine growth retardation, especially with early and prolonged use. 1, 6
Use Only in Severe, Refractory Cases
Low-dose diazepam and diuretics may be considered only in severe, refractory Meniere's disease with extreme caution, representing a last-resort option. 2
Systemic prednisone or prednisolone can be considered in selected severe cases when other options have failed. 2
Critical Timing Considerations
Avoid all medications during the first trimester when possible, as this period carries the highest risk of congenital malformations per American College of Cardiology recommendations. 1, 6
Non-selective NSAIDs may be used until the 32nd week if needed for associated symptoms, but must be discontinued thereafter. 2, 5
Common Pitfalls to Avoid
Do not prescribe vestibular suppressants as primary treatment for BPPV, as they lack evidence for definitive treatment and may interfere with central compensation mechanisms. 1
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. 1
New headache with hypertension must be evaluated for preeclampsia before attributing symptoms to benign vertigo, per American College of Obstetricians and Gynecologists guidance. 1
Persistent symptoms after repositioning maneuvers may indicate incorrect diagnosis rather than treatment failure. 1
Postpartum Management
Paracetamol is preferred for migraine-related vertigo during breastfeeding, per American Academy of Pediatrics recommendations. 1
Propranolol has the best safety profile for preventive therapy during breastfeeding if chronic suppression is needed. 1
Ibuprofen is safe as first-line for postpartum pain per American College of Obstetricians and Gynecologists. 1