Title : The role of calcitonin gene related peptide and associated treatment strategies for refractory vestibular migraine: A case study
Abstract:
Summary/Objective:
To describe a patient who developed refractory vestibular migraine after a motor vehicle accident (MVA) and COVID-19 infection with subsequent improvement while on multiple CGRP antagonists with off-label dosing and to provide support for the role of CGRP in vestibular migraine.
Background:
Previous studies have found a significant association between elevated calcitonin gene related peptide (CGRP) plasma levels during migraine episodes, though little is known regarding the underlying mechanism for vestibular migraine subtype (VM). There is prior evidence in a study using rats to suggest a possible role of this peptide in the sensitization of the vestibular nuclei in chronic migraine, however. In addition, one small retrospective study found that 18 out of 25 patients treated with CGRP antagonists developed global improvement in both vertigo and migraine headache symptoms. Overall, there is still a paucity of information regarding the most efficacious treatment strategies for refractory cases of VM with CGRP antagonists.
Methods:
A case report with literature review. PubMed literature review with MeSH terms “migraine disorder” and “calcitonin gene-related peptide” revealed 900 results.
Results:
A male in his 40’s with hx of chronic myeloid leukemia developed 3 months of persistent vestibular migraine with circumferential headache, vertigo, and photophobia 3 days after a motor vehicle accident (MVA) with associated head trauma but without loss of consciousness. A magnetic resonance imaging (MRI) of the brain with and without contrast revealed no acute ischemic stroke or hemorrhage. He developed a severe COVID-19 pneumonia with hypoxia requiring intubation for 22 days. Post-hospitalization, he continued to have symptoms consistent with vestibular migraine including spontaneous vertigo, positional vertigo when leaning forward, and circumferential headache with associated photophobia. The patient was started galcanezumab with 2 weeks of relief, followed by refractory symptoms unrelieved with erenumab, rimepegnant, and fremanezumab. The patient received a first dose 100mg of eptinezumab, followed by fremanezumab at 6 weeks, a second dose of 100mg eptinezumab off-label at 7 weeks, and 300mg of eptinezumab at 12 weeks which finally resulted in the desired outcome of long-lasting relief for several months on outpatient hospital follow up.
Conclusion:
CGRP likely plays an important role in the pathophysiology of VM. Additional off-label dosing of CGRP antagonists may be helpful to alleviate refractory VM.
Audience Take Away
- Pathophysiology of vestibular migraine
- To describe a patient who developed refractory vestibular migraine after a motor vehicle accident (MVA) and COVID-19 infection with subsequent improvement while on multiple CGRP antagonists with off-label dosing and to provide support for the role of CGRP in vestibular migraine
