From the Guidelines
For migraines occurring weekly with vomiting, I recommend a comprehensive treatment approach combining preventive and acute medications, prioritizing the use of a nonoral triptan and an antiemetic for acute attacks, as suggested by the most recent guideline from the American College of Physicians 1.
Key Considerations
- The choice of a specific NSAID or triptan should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1.
- For acute treatment during attacks, consider using a triptan like sumatriptan or rizatriptan, combined with an antiemetic such as ondansetron or promethazine to manage vomiting 1.
- Identify and avoid personal triggers, maintain a consistent sleep schedule, stay hydrated, and consider keeping a headache diary to track patterns.
- Non-medication approaches like stress management techniques, regular exercise, and biofeedback may also help reduce frequency and severity.
Preventive Medications
- Consider a daily preventive medication such as topiramate, propranolol, or amitriptyline, as these have been recommended for migraine prevention 1.
Acute Treatment
- Use a nonoral triptan and an antiemetic for acute attacks, especially in patients with significant nausea or vomiting, as this approach is supported by the guideline 1.
- Take acute medications at the earliest sign of migraine for best effectiveness.
Patient Education
- Educate patients about the control of acute attacks and preventive therapy, and engage them in the formulation of a management plan, as emphasized in the guideline 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Management of Migraines with Symptoms Once a Week with Vomiting
- Migraine is a paroxysmal disorder with attacks of headache, nausea, vomiting, photo- and phonophobia, and malaise 2.
- For acute migraine treatment, analgesics like acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs), and combination products that include caffeine can be used 3.
- Patients not responsive to these treatments may require migraine-specific treatments including triptans (5-HT1B/D agonists), which eliminate pain in 20% to 30% of patients by 2 hours 3.
- Antiemetics can be used as supplement to alleviate nausea and vomiting 4.
- Preventive treatments include antihypertensives, antiepileptics, antidepressants, calcitonin gene-related peptide monoclonal antibodies, and onabotulinumtoxinA, which reduce migraine by 1 to 3 days per month relative to placebo 3.
Treatment Options
- Triptans (almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, sumatriptan, and zolmitriptan) are highly effective in treating migraine attacks and improve headache as well as nausea, photo- and phonophobia 2.
- Beta-blockers (metoprolol and propranolol), calcium channel blocker (flunarizine), and amitriptyline are recommended for migraine prophylaxis 2, 5.
- Antiepileptic drugs (valproic acid, gabapentin, topiramate) have been evaluated for the prophylaxis of migraine 2, 5.
Considerations
- The choice of prophylactic drugs depends on efficacy, co-morbidity, side effects, availability, and cost 5.
- Non-pharmacological treatments such as relaxation techniques, bio-feedback, cognitive behavioral therapy, and acupuncture are supported by some evidence but require far more specialist time or technical devices 5.
- Patients with or at high risk for cardiovascular disease should avoid triptans because of vasoconstrictive properties 3.