CGRP monoclonal antibodies consistently improve vestibular migraine symptoms in observational studies
Background
Vestibular migraine (VM) is a prevalent yet often underdiagnosed cause of episodic vertigo, for which effective, evidence-based preventive treatments are critically lacking. Current standard-of-care options are often suboptimal, leading to significant quality of life impairment. Calcitonin gene-related peptide (CGRP) plays a central role in the pathogenesis of migraine and is also expressed within vestibular structures, providing a strong biological rationale for investigating CGRP-targeting therapies in VM. Despite this, a systematic synthesis of the available evidence has been absent until now, leaving a significant gap in understanding their potential efficacy.
Study Design
Researchers conducted a structured synthesis of studies evaluating CGRP-targeting therapies (both monoclonal antibodies and gepants) in adult patients diagnosed with definite or probable vestibular migraine. A comprehensive search was performed across PubMed/MEDLINE, Embase, Scopus, and Web of Science. Eligible studies included randomized controlled trials (RCTs), prospective/retrospective cohorts, and case series with at least 10 patients reporting quantitative outcomes. A two-tier synthesis approach was pre-specified: quantitative meta-analysis if sufficient homogeneity allowed, otherwise a narrative synthesis coupled with a direction-of-effect analysis to assess consistent trends.
Results
Out of 247 initial records, only four observational studies met the stringent inclusion criteria, encompassing a total of approximately N ≈ 103 patients. Notably, no randomized controlled trials (RCTs) evaluating CGRP-targeting therapies for VM were identified. All four included studies specifically evaluated CGRP monoclonal antibodies; no gepant studies met the inclusion criteria. Due to significant heterogeneity in outcome reporting across the studies, a quantitative meta-analysis was not feasible. However, the direction-of-effect synthesis revealed a consistent pattern of improvement across all evaluated outcomes.
Vertigo frequency consistently improved in 4/4 studies, Dizziness Handicap Inventory scores improved in 2/2 studies where reported, and monthly migraine days also showed improvement in 2/2 studies. Importantly, the synthesis found no reports of serious adverse events associated with CGRP monoclonal antibody use in these VM patient cohorts, suggesting a favorable safety profile.
Key Findings
- CGRP monoclonal antibodies consistently improved vertigo frequency in 4/4 observational studies.
- Dizziness Handicap Inventory scores improved in 2/2 studies reporting this outcome.
- Monthly migraine days decreased in 2/2 studies where this was reported.
- No serious adverse events were reported across all included studies (N ≈ 103).
Why It Matters
This synthesis provides the first systematic overview of CGRP-targeting therapies for vestibular migraine, suggesting a consistent benefit for key symptoms like vertigo frequency and dizziness handicap, alongside migraine days. Clinicians may consider CGRP monoclonal antibodies as a potential therapeutic option for VM patients, given the current lack of evidence-based treatments and the favorable safety profile observed. However, it is crucial to acknowledge that these findings are based solely on observational data. The absence of controlled trials means this is not yet a definitive, widely applicable protocol. This work highlights an urgent need for adequately powered, double-blind, placebo-controlled RCTs to establish robust efficacy and safety, paving the way for CGRP-targeting therapies to become a standard-of-care for VM.
vestibular migraine
cgrp
monoclonal antibody
gepant
migraine
vertigo