What to give to a patient vomiting with migraine?

From the Guidelines

For a patient experiencing vomiting with migraine, I recommend an antiemetic medication such as metoclopramide (10mg), ondansetron (4-8mg), or prochlorperazine (5-10mg), which can be given orally, intravenously, or as a suppository depending on the severity of vomiting. These medications should be administered at the onset of symptoms and can be repeated as needed according to the specific medication's dosing guidelines 1. In addition to antiemetics, ensure the patient stays hydrated with small sips of clear fluids and considers taking their migraine-specific medication (like triptans) if they haven't already, as treating the underlying migraine often helps resolve the nausea and vomiting. For severe cases, intravenous fluids may be necessary to prevent dehydration. Antiemetics work by blocking dopamine or serotonin receptors in the chemoreceptor trigger zone of the brain, which helps control the vomiting center. Having the patient rest in a dark, quiet room can also help reduce sensory stimulation that may worsen both the migraine and associated nausea. If vomiting persists despite these measures, medical attention should be sought promptly.

Some key points to consider when treating a patient with vomiting and migraine include:

• Treating nausea and vomiting with an antiemetic is crucial, as nausea itself is one of the most aversive and disabling symptoms of a migraine attack 1
• Selecting a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex 1
• Ensuring the patient stays hydrated and considering the use of migraine-specific medications, such as triptans, if necessary 1
• Educating the patient about the control of acute attacks and preventive therapy, and engaging them in the formulation of a management plan 1

It's also important to note that the evidence for the use of certain medications, such as acetaminophen alone, is limited, and other options, such as NSAIDs, triptans, and ergotamines, may be more effective for treating migraine headaches 1. However, the choice of medication should be individualized based on the patient's specific needs and medical history.

From the FDA Drug Label

For patients with migraine-associated nausea, photophobia, and/or phonophobia at baseline, there was a lower incidence of these symptoms at 2 hours (Trial 1) and at 4 hours (Trials 1,2, and 3) following administration of sumatriptan tablets compared with placebo

The patient vomiting with migraine can be given sumatriptan tablets as it has been shown to reduce the incidence of nausea, one of the associated symptoms of migraine. However, it is crucial to note that the label does not specifically address vomiting, but rather nausea, which is often associated with migraine. Given the information available, sumatriptan may be considered as an option for treating migraine, potentially alleviating some symptoms that may be related to or exacerbate vomiting, such as nausea. 2

From the Research

Treatment Options for Migraine with Vomiting

• Metoclopramide is effective as primary therapy for acute migraine, and it can be used to treat vomiting associated with migraine 3.
• The optimal dose of metoclopramide for acute migraine is not yet known, but 10 mg, 20 mg, and 40 mg doses have been studied, with 20 mg or 40 mg being no better than 10 mg 3.
• Intravenous valproate is similar in effectiveness to dihydroergotamine/metoclopramide as abortive therapy for prolonged moderate-to-severe acute migraine headache, and it may be a safe and well-tolerated treatment option 4.

Antiemetic Therapy for Nausea and Vomiting

• Antiemetic agents such as droperidol, promethazine, prochlorperazine, metoclopramide, and ondansetron can be used to treat nausea and vomiting in the emergency department 5.
• Ondansetron is as effective as promethazine and is not associated with sedation or akathisia, making it a potential first-line agent for relief of nausea or vomiting in most patient populations 5.
• A randomized controlled trial comparing ondansetron, metoclopramide, and placebo found similar reductions in nausea severity for all three groups, with a trend toward greater reductions in VAS ratings and a lesser requirement for rescue medication in the antiemetic drug groups 6.

Considerations for Treatment

• Patients given prochlorperazine or metoclopramide must be monitored for akathisia, which can develop at any time over 48 hours post-administration 5.
• Decreasing the infusion rate can reduce the incidence of akathisia, and the effect can be treated with intravenous diphenhydramine 5.
• The choice of antiemetic agent should be based on the individual patient's needs and medical history, as well as the potential side effects and interactions of each medication 5, 6.