Effectiveness and clinical predictors of rimegepant for acute vertigo in vestibular migraine: A real-world cohort study

AimIn view of limited evidence-based acute treatments for spontaneous vertigo in vestibular migraine, this real-world cohort study assessed the effectiveness of rimegepant for acute vestibular migraine-related vertigo and factors associated with treatment response.MethodsClinical data were retrospectively collected from 86 patients with documented vestibular migraine treated with rimegepant 75 mg orally disintegrating tablets for acute attacks at a tertiary referral hospital between March and November 2025. Predictors of 2-h vertigo relief, defined as improvement from moderate or severe baseline vertigo to mild or no vertigo on an 11-point numeric rating scale, and 2-h numeric rating scale scores were analyzed using regression models accounting for within-patient clustering of attacks.ResultsAmong 86 patients, 192 of 252 treated vertigo episodes (76.2%) achieved vertigo relief. At 2 h after dosing, the mean change in vertigo numeric rating scale score was -4.44 (95% CI, -4.65 to -4.23). In adjusted models, age younger than 60 years (OR, 3.45 [95% CI, 1.15 to 10.31]; P = 0.027) and lower baseline numeric rating scale (OR per 1-point increase, 0.56 [95% CI, 0.36 to 0.86]; P = 0.008) were associated with higher odds of vertigo relief. Younger age, lower baseline numeric rating scale score, and better hearing (β, -1.14 [95% CI, -2.02 to -0.26]; P = 0.013) were also associated with lower 2-h numeric rating scale scores.ConclusionRimegepant was effective for vertigo episodes in patients with vestibular migraine, and treatment responsiveness was closely associated with age, baseline vertigo severity, and auditory function. These findings support the early initiation of rimegepant for acute treatment of vestibular migraine, rather than delaying treatment until vertigo exacerbation.