BPPV is a very common form of dizziness (lifetime prevalence 2.4%) and has been noted to have an association with migraine. The cause of otoconia displacement in BPPV is often unclear. A vascular mechanism theory has been postulated in varying research. The authors conducted a case–control study to determine whether recurrent vasospasms associated with migraine attacks, combined with the use of commonly prescribed triptan medications (which are known to be vasoconstrictive), have any statistically significant impact. They utilised electronic health record data in the US encompassing 117 million patients from January 2019 to January 2024. They identified 39,456 patients with a pre-dated migraine and vestibular disorder diagnosis. They stratified data in a number of ways including looking at use of triptans and calcitonin gene-related peptide (CGRP) antagonists (second line following triptan use in most UK guidelines and not known to be vasoconstrictive). Results reveal that among migraine patients of all ages (over 18 years) 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). The results of the study suggest that an association exists between the patient’s choice of migraine abortive medication and their odds of developing BPPV (1.32 odds ratio and interestingly highest in younger age group with odds ratio 1.74 for ages 18-44). The authors note several limitations to the study. Its case-control design limits the ability to determine cause and effect. In addition, patient classification relied solely on diagnostic codes, and the duration of medication use was unknown, among other constraints. However, the number of patients certainly adds to the statistical power. In practice, given the frequency of migraine and dizziness in ENT referrals, patients with BPPV who are using triptans for migraine may warrant consideration for switching to CGRP antagonists, such as gepants, in accordance with UK acute migraine treatment guidelines.
Migraine medication and benign paroxysmal positional vertigo (BPPV)
Reviewed by Aaron Ferguson
Effect of Migraine Abortive Drugs on Benign Paroxysmal Positional Vertigo Odds: A Database Analysis.
