For individuals with weaker correlations between vestibular and migraine symptoms, the ICVD included a diagnosis of probable vestibular migraine. There is no level 1 evidence to support the widespread use of migraine-recommended medications to treat vestibular migraine. The main goal of this study was to close this gap by testing the safety and effectiveness of rizatriptan for the acute treatment of vestibular migraine episodes in a double-blind, placebo-controlled RCT.
This double-blind, randomized clinical study of rizatriptan vs placebo was carried out at two tertiary neurotologic facilities between December 2014 and July 2020 (data analysis in 2021 and sensitivity analyses in 2022 and 2024). The participants were adults with vestibular migraine. Thus, to treat up to three vestibular migraine attacks per participant, each individual was randomized in a 2:1 ratio to receive either rizatriptan 10 mg or a placebo after undergoing prospective observation to confirm diagnosis and sickness activity.
A total of 307 attacks were treated by 134 (60.4%) of the 222 participants who were unwell. 240 attacks with moderate to severe vestibular symptoms during study medication use were used to determine efficacy. Rizatriptan did not differ from a placebo at one hour in terms of lowering vertigo, dizziness, or any other side effects. After an hour, comparable proportions of individuals in the rizatriptan and placebo groups added rescue medications.
When compared to a placebo, rizatriptan demonstrated moderate effects on motion sensitivity and unsteadiness/dizziness after 24 hours. A medium impact favoring rizatriptan for headache and photophobia or phonophobia at 24 hours was revealed by post hoc analysis of all treated events. There was mixed satisfaction with the treatment. None of the individuals had severe side effects or stopped taking their medication because of them.
Overall, these findings refute the idea that rizatriptan should be used regularly to manage vestibular migraine episodes. At one hour, it had no impact on vertigo and was ineffective for any symptoms. The side effects were mild and in line with earlier findings.
Source:
Staab, J. P., Eggers, S. D. Z., Jen, J. C., LeMahieu, A. M., Geske, J. R., Liu, H., Hofschulte, D. R., Gonzalez, G. R., Neff, B. A., Shepard, N. T., McCaslin, D. L., & Baloh, R. W. (2025). Rizatriptan vs placebo for attacks of vestibular migraine: A randomized clinical trial. JAMA Neurology. https://doi.org/10.1001/jamaneurol.2025.1006
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