Phenotype-guided selection of venlafaxine and topiramate for vestibular migraine: a narrative review.

Vestibular migraine (VM) is a common but underdiagnosed cause of recurrent vertigo. Its heterogeneous manifestations and the lack of validated biomarkers complicate diagnosis, and emerging evidence supports individualized rather than uniform preventive strategies. Among available prophylactic options, venlafaxine and topiramate are two clinically important agents with distinct mechanisms and therapeutic profiles. They are discussed here as illustrative exemplars rather than exclusive preferential choices. Venlafaxine may be a reasonable option to consider for patients with comorbid anxiety or depression, visually induced dizziness, persistent postural-perceptual dizziness (PPPD) overlap, or marked emotional and functional impairment. In contrast, topiramate may be more suitable for patients with a headache-predominant phenotype, pronounced sensory hypersensitivity, or a greater need for conventional migraine prophylaxis. Current studies suggest that both agents can reduce vestibular symptom burden; however, the overall quality of evidence remains limited by small sample sizes, heterogeneous diagnostic criteria, mixed inclusion of probable and definite VM, and inconsistent outcome measures. This review summarizes the current evidence comparing the two drugs, critically discusses their respective therapeutic roles, and proposes a pragmatic phenotype-guided framework for clinical decision-making. We emphasize that treatment selection should consider not only attack frequency and vertigo severity, but also psychiatric comorbidity, PPPD overlap, headache predominance, body-weight concerns, cognitive vulnerability, and functional recovery goals. Further phenotype-stratified prospective studies are needed to validate precision treatment strategies for VM.