CGRP-Targeted Therapy in Vestibular Migraine-How Strong Is the Evidence?

Medications for migraine prevention targeting the calcitonin gene-related peptide (CGRP) pathway have substantially reduced symptom burden in many patients that have failed previous treatment strategies. In contrast, data on treatment response to monoclonal antibodies (mAbs) or small molecule receptor antagonists (gepants) in patients suffering from vestibular migraine (VM) is scarce and preliminary.

We discuss the existing literature on VM-prevention using mAbs and gepants with a special focus on biases and limitations such as small sample sizes, retrospective study design, lack of blinding, and patient selection.

Studies identified (n = 8) assessed different mAbs and gepants and generally reported improvement of vestibular symptoms and scores used, but were often of small sample size and lacked blinding and control groups. In a single randomized controlled trial, a significant treatment response to galcanezumab was identified, with a medium to large effect size (ranging between 0.56 and 1.02) for dizzy days reported and on scores applied (dizziness handicap inventory [DHI] and Vestibular Migraine Patient Assessment Tool and Handicap Inventory [VM-PATHI]).

Data on anti-CGRP treatments for VM remain limited, and efficacy established in headache migraine cannot be straightforwardly extrapolated to VM given differences in underlying pathophysiology. There remains a risk that initial effect estimates may diminish over time, with early outcomes partially inflated by a novelty effect, expectancy, and more nuanced methodological approaches. Targeted treatment options for this common and often debilitating condition are genuinely welcomed, but the current evidence warrants careful interpretation for CGRP-related therapies.