New Anti-CGRP Medications in the Treatment of Vestibular Migraine

Abstract

BackgroundVestibular migraine (VM) is a condition associated with migraine headache, vertigo, dizziness, and balance disturbances. Treatment options are limited. It is unknown if new calcitonin gene-related peptide (CGRP) migraine medications have efficacy in treating VM.MethodsWe retrospectively reviewed all patients with VM who were prescribed one of the new CGRP medications between January 2016 and July 2020. In total, 28 patients met the inclusion criteria. We specifically evaluated the “older” CGRP medications including erenumab, galcanezumab, fremanezumab, and ubrogepant. Medical records for subsequent visits were assessed to monitor improvement described by patients.ResultsOf the 28 patients identified, three were lost to follow up. For the remaining 25 patients, we divided the patients based on a scale of “significant improvement,” “moderate improvement,” “mild improvement,” or “no improvement.” In total 21 of 25 patients demonstrated some level of improvement in their VM symptoms with 15 having moderate to significant improvement.ConclusionResults demonstrated a trend toward improvement, suggesting that the CGRP medications appear to be a decent treatment option for VM. A prospective study evaluating CGRP medications in patients with VM would provide further information about this treatment option.

Systemic Calcitonin Gene-Related Peptide (CGRP) modifies auditory and vestibular endorgan electrical potentials, and increases sensory hypersensitivities

“…Clinical studies on effectiveness of CGRP monoclonal antibodies are underway for VM, using the newly developed VM-PATHI instrument to score outcome measures (Sharon JD et al, 2020). A recent case review has found that 60% of patients with VM have their VM symptoms moderately relieved with CGRP signaling blockers (Hoskin JL and Fife TD, 2022).…”

Recognizing vestibular migraine

“…8 Current research suggests that a change in ion channel function results in altered neural activity in the trigeminovascular system, which results in release of neurotransmitters such as substance P and calcitonin gene-receptor peptide (CGRP). 9 Receptors for CGRP are expressed in the vestibular system and have been associated with motion sickness. 9 Activation of this system likely is a contributing factor for the pathophysiology of vestibular migraine.…”

“…3,8 The most frequent vertigo symptoms in vestibular migraine are spontaneous rotatory vertigo and positional vertigo but patients also may experience visually induced vertigo and head motion-induced vertigo. 3,9 Patients are most likely to describe a sense of spinning, fl oating, rocking, tilting, swaying, feeling off-balance, lightheaded, or foggy. 1 Vestibular symptoms are often triggered or aggravated by changing position, movement, or visual motion within the patient's environment.…”

“…14 A small retrospective study by Hoskin and Fife demonstrated a trend toward improvement in vestibular migraine patients treated with some of these medications. 9 Further study is needed to determine their full effectiveness for treatment and prevention of vestibular migraine.…”

“…Patients with a history of migraine have a low threshold activation of the connections between the trigeminal and vestibular systems 8. Current research suggests that a change in ion channel function results in altered neural activity in the trigeminovascular system, which results in release of neurotransmitters such as substance P and calcitonin gene-receptor peptide (CGRP) 9. Receptors for CGRP are expressed in the vestibular system and have been associated with motion sickness 9.…”