CGRP-Targeting Therapies in Vestibular Migraine: A Synthesis of Observational Evidence with Direction-of-Effect Analysis
Abstract
Background: Vestibular migraine (VM) is a common but underdiagnosed cause of episodic vertigo lacking evidence-based preventive treatments. Calcitonin gene-related peptide (CGRP) plays a central role in migraine pathogenesis and is expressed in vestibular structures, providing a rationale for CGRP-targeting therapies in VM. However, available evidence has not been systematically synthesized.
Methods: We conducted a structured synthesis of studies evaluating CGRP-targeting therapies (monoclonal antibodies and gepants) in adults with definite/probable VM. We searched PubMed/MEDLINE, Embase, Scopus, and Web of Science. Eligible studies included randomized controlled trials, prospective/retrospective cohorts, and case series (≥10 patients) reporting quantitative outcomes. A two-tier synthesis was prespecified: quantitative meta-analysis where feasible, otherwise narrative synthesis with direction-of-effect analysis.
Results: Of 247 records, four observational studies met inclusion criteria (total N ≈ 103 patients). No RCTs were identified. All four studies evaluated CGRP monoclonal antibodies; no gepant studies met inclusion criteria. Outcome reporting was highly heterogeneous. Quantitative meta-analysis was not feasible. Direction-of-effect synthesis showed consistent improvement across all studies for vertigo frequency (4/4), Dizziness Handicap Inventory (2/2), and monthly migraine days (2/2). No serious adverse events were reported.
Conclusions: CGRP monoclonal antibodies…
How strong is the evidence?
Evidence Hub reads this as a meta-analysis, done in people. Its evidence level is 1 of 5 (Highest · pooled evidence). Pooled evidence from several studies sits at the top of the evidence pyramid. Reported size: 103 participants or records.
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