Effect of Migraine Abortive Drugs on Benign Paroxysmal Positional Vertigo Odds - A Database Analysis

Introduction: Patients with migraine may be more susceptible to benign paroxysmal positional vertigo (BPPV) than the general population. Although the underlying pathophysiology remains uncertain, it has been postulated that recurrent vasospasms associated with migraine attacks may cause inner ear ischemia and changes in endolymph pressure. Currently, there are no specific recommendations for preventing BPPV in this vulnerable patient population. Among commonly used migraine abortive drugs, triptans, which are selective serotonin agonists, are known to be vasoconstrictive, whereas calcitonin gene-related peptide (CGRP) antagonists are not. This population-based study uses a federated electronic medical record (EMR) database to characterize the prevalence of BPPV among migraine patients and its relevance to their choice of abortive drug. Methods: In this case-control study, EMR data from the TriNetX US Collaborative Network was queried for subjects who were seen at a participating healthcare organization for a vestibular disorder (ICD10: H81) between 2019 and 2024. Subjects must also have a concomitant, pre-existing diagnosis of migraine (G43). These patients were stratified by age (18-44, 45-64, 65+ years) and sex. The resulting cohorts were then divided into those with and without a BPPV diagnosis (H81.1). Patients with prior documented head trauma (S02, S06, S09), middle or inner ear surgery, or vitamin D deficiency (E55) were excluded. The prevalence of pre-existing triptan and CGRP antagonist use of each BPPV cohort was compared against the non-BPPV cohort of the same age and sex using Chi-square analysis. Results: As expected, the female subject population had significantly higher prevalence of migraine (17.06% vs 7.26%, p<0.0001) than the males. Among migraine patients of all ages and sexes, triptan use was significantly more common among BPPV patients than non-BPPV patients (30.90% vs 25.35%, p<0.0001). Conversely, CGRP antagonists were more commonly used by non-BPPV patients than by BPPV patients (3.17% vs 2.45%, p=0.0005). Conclusion: This study shows that, among patients with vestibular disorders, migraine patients with BPPV are more often exposed to triptans, and less to CGRP antagonists, than those without BPPV. Triptans may increase the prevalence of BPPV by potentiating vasoconstriction during migraine attacks, which may result in inner ear ischemia and alterations of endolymphatic pressure, while CGRP antagonists do not. Therefore, CGRP antagonists may be preferrable over triptans for preventing BPPV in migraine patients.