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BACKGROUND: Vestibular migraine (VM) is a neurological disorder characterized by episodic vertigo in patients with migraine, contributing to substantial functional impairment. Although VM is relatively common, a consensus on effective prophylactic treatments is lacking. This systematic review aimed to evaluate the efficacy and safety of pharmacological and adjunct non-pharmacological interventions for VM management. METHODS: The systematic review was conducted following the PRISMA 2020 guidelines. PubMed, Web of Science, and Google Scholar were searched from inception to April 2025. Randomized controlled trials or cohort (retrospective and prospective) studies assessing prophylactic pharmacological or adjunct non-pharmacological management in adults diagnosed with VM were included. The risk of bias was evaluated using the Cochrane RoB 2 and MINORS tools. RESULTS: Nine studies (three RCTs, six cohort studies; total n = 687) met the inclusion criteria. Beta-blockers, particularly propranolol, and antiepileptics, such as topiramate, consistently reduced VM symptoms, as measured using validated scales (Dizziness Handicap Inventory, Vertigo Symptom Scale, and Vestibular Activities of Daily Living). Anti-CGRP monoclonal antibodies (erenumab and galcanezumab) showed favorable efficacy and tolerability. By contrast, calcium channel blockers and antidepressants yielded inconsistent outcomes. Vestibular rehabilitation, when used as an adjunct therapy, demonstrated functional benefits. Reported adverse effects were generally mild and treatment specific. Substantial heterogeneity in treatment protocols, outcome assessments, and follow-up intervals precluded meta-analysis; therefore, findings were synthesized qualitatively. CONCLUSION: Moderate-quality evidence supports the use of propranolol and topiramate as first-line prophylactic treatments for VM. Emerging data suggest that anti-CGRP agents may be beneficial for refractory cases. Larger, rigorously designed trials are necessary to establish standardized and individualized treatment protocols.