What is the initial treatment approach for a patient with gastric migraine?

Initial Treatment Approach for Gastric Migraine

For patients with gastric migraine, NSAIDs such as aspirin, ibuprofen, or naproxen sodium should be used as first-line treatment, along with an antiemetic such as metoclopramide or domperidone to address nausea and vomiting symptoms. 1

First-Line Treatment Algorithm

• Start with NSAIDs as the primary treatment for most migraine sufferers, including those with prominent gastric symptoms 1

  • Options include:
    • Aspirin 1000 mg
    • Ibuprofen 400-800 mg
    • Naproxen sodium 500-1000 mg
    • Diclofenac potassium
  • Note: Acetaminophen alone has insufficient evidence for efficacy in migraine 1, 2

• For patients with significant nausea or vomiting (gastric migraine), add a prokinetic antiemetic 1:

  • Metoclopramide 10 mg orally (or 20 mg as suppository)
  • Domperidone 20 mg orally
  • Administer antiemetic 15-20 minutes before analgesic to enhance absorption 3

• Select a non-oral route of administration if vomiting is severe or occurs early in the attack 1

  • Consider suppositories or nasal formulations to bypass the gastrointestinal tract

Second-Line Treatment

• If NSAIDs with antiemetics fail to provide adequate relief, use migraine-specific agents (triptans) 1:

  • Sumatriptan 50-100 mg orally
  • Rizatriptan, zolmitriptan, or naratriptan orally
  • Sumatriptan 6 mg subcutaneously for severe attacks or when oral administration is not feasible 4, 5

• Triptans have demonstrated efficacy similar to aspirin 1000 mg but may be more effective for moderate to severe attacks 6, 5

• The combination of aspirin plus metoclopramide has shown efficacy comparable to sumatriptan 100 mg 6, 2

Important Clinical Considerations

• Administer medications as early as possible in the headache phase for maximum effectiveness 1

• Warn patients about medication overuse headache risk; limit acute treatment to no more than twice weekly 1

• Avoid oral ergot alkaloids, opioids, and barbiturates due to poor efficacy, toxicity, and dependency risk 1

• Consider preventive therapy if:

  • Attacks occur ≥2 times per month with disability lasting ≥3 days 1
  • Acute treatments fail or are contraindicated 1
  • Acute medications are needed more than twice weekly 1

Monitoring and Follow-up

• Evaluate treatment response after each attack 1

  • Pain relief within 2 hours
  • Freedom from associated symptoms (nausea, vomiting, photophobia, phonophobia)
  • Need for rescue medication

• Document frequency, severity, and duration of attacks to guide treatment adjustments 1

• If initial treatment fails, consider combination therapy (triptan plus NSAID) before moving to third-line options 1

• For patients with frequent gastric migraine attacks requiring regular medication, evaluate for preventive therapy to reduce attack frequency and severity 1