Monoclonal Antibodies Targeting CGRP: A Novel Treatment in Vestibular Migraine

Abstract

Background. Monoclonal antibodies (mAbs) directed against the calcitonin gene-related peptide (CGRP) or its receptor represented the first targeted and specialized approach to migraine prophylaxis. Nevertheless, they have been rarely considered in the treatment of vestibular migraine (VM). Our aim was to evaluate the effectiveness of anti-CGRP mAbs in VM patients who did not respond to conventional migraine treatments. Methods. Consecutive VM patients treated with erenumab were considered. As a comparison, we considered the same VM patients during conventional migraine treatments (i.e., propranolol, flunarizine, or valproic acid), which were tried before mAbs therapy. Videonystagmography, the Italian version of the Dizziness Handicap Inventory (DHI) questionnaire, and migraine days over the last 3 months were evaluated in all patients before and after treatments. Results. In the present retrospective study, we included 21 female and 2 male VM patients, mean age 45.2 years. All patients underwent contrast-enhanced magnetic resonance imaging that ruled out other causes of vertigo. The DHI questionnaire significantly improved after mAb therapy (p < 0.0001). Mean migraine days over the last 3 months were significantly reduced after treatment (p = 0.001). Videonystagmography was altered in 11 (48%) patients prior to monoclonal antibodies. We found vertical positional nystagmus in 9 patients and horizontal positional nystagmus in 2 patients. After the treatment, we found vertical positional nystagmus only in 1 patient (p = 0.002). When patients were treated with conventional therapies, there was no significant reduction in DHI, and instrumental vestibular examinations remained altered. Conclusions. VM patients using anti-CGRP mAbs experienced a reduction in the dizziness-derived handicap, as reported in the DHI questionnaire. Furthermore, these treatments were significantly associated with a normalization of vestibular instrumental analysis. These findings were not seen with conventional treatments. Treatment with anti-CGRP mAbs may be effective in VM patients who did not respond to conventional migraine treatments. These findings should be tested in large, randomized clinical trials.

Advances in diagnosis and treatment of vestibular migraine and the vestibular disorders it mimics

“…All these treatments have undergone intense scrutiny for the treatment of migraine, however there is a paucity of data on their effectiveness for VM, as no randomized controlled trials of these therapies exist. However emerging evidence suggests that these CGRP antagonists may be beneficial for VM in the same way they are effective for migraine headache [ [39] , [40] , [41] ]. In the author's experience, when patients have failed other migraine therapies, these appear anecdotally to be an effective option.…”

Human RAMP1 overexpressing mice are resistant to migraine therapies for motion sensitivity

“…Early studies targeting CGRP with olcegepant have led to the development of improved "gepants" and monoclonal antibodies that can block either the CGRP receptor or the peptide. Numerous treatment options for migraines based on antagonizing CGRP signaling have been investigated in clinical trials, many of which have been approved by the FDA since 2018, and a few studies have indicated that CGRP antagonists have been successful in treating vestibular migraines, particularly in a subset of patients 19, 20 . Alternative treatments, such as vestibular suppressants, have not been shown to alleviate vertigo and may cause drowsiness 21–23 .…”