Contemporary diagnosis and management of vestibular migraine: a systematic review of conventional and CGRP-targeted therapies

Background Vestibular migraine (VM) is a common cause of recurrent episodic vertigo, and it is associated with significant disability from recurrent vestibular and migraine symptoms. While there are a number of standard preventive treatments, their effectiveness is quite variable, and new treatments which target calcitonin gene-related peptide (CGRP) have been identified as potential treatments. The purpose of this systematic review was to assess the state of the art in the diagnosis of vestibular migraine and to compare the efficacy of conventional pharmacological treatments with the new CGRP-targeted treatments. Methods A systematic literature review was performed to find studies that assessed the diagnosis and pharmacological treatment of vestibular migraine. Randomized controlled trials, observational studies, comparative studies, retrospective analysis, cross-sectional studies, and case reports of patients with definite or probable vestibular migraine were included. Study characteristics, diagnostic methods, therapeutic interventions, clinical outcomes, and treatment efficacy were qualitatively extracted and synthesized. Results 21 studies were included with a total of over 12,000 participants. The evidence comprised predominantly adult VM populations together with one large pediatric multicenter study. Among adult studies, participants were predominantly middle-aged women. The Bárány Society/ICHD criteria were used as a primary basis for the diagnostic evaluation, with selective tests of the vestibular system and neuroimaging to rule out alternative diagnoses. conventional preventive therapies were associated with reductions in vertigo frequency, headache burden, and dizziness-related disability. Anti-CGRP therapies including erenumab, fremanezumab, galcanezumab, rimegepant, and ubrogepant, were associated with clinically meaningful improvements in vertigo frequency, monthly dizziness days, disability scores, headache outcomes, and patient-reported quality of life. Conclusion A multimodal approach to the clinical evaluation of vestibular migraine is supported by current evidence, and both traditional preventive treatments and CGRP-targeted treatments have demonstrated benefit across vestibular and migraine-related outcomes. CGRP-targeted therapies represent a promising emerging therapeutic option, particularly for patients with persistent or refractory symptoms. however, the limited randomized evidence and scarcity of direct head-to-head comparisons with conventional therapies preclude firm conclusions regarding their comparative effectiveness. Systematic review registration: identifier: CRD420261427685.