First-Line Medication for Acute Migraines with Nausea
For patients with acute migraines who experience nausea, a non-oral route of administration should be selected, along with an antiemetic medication to treat the nausea. 1, 2
Treatment Algorithm for Migraines with Nausea
First-Line Approach
- Select a non-oral route of administration when nausea is a significant component of migraine attacks 1, 2
- Add an antiemetic medication to specifically target the nausea symptoms 1, 2
- For mild to moderate attacks, use NSAIDs via non-oral routes when possible 1
- For moderate to severe attacks, use triptans via non-oral routes (e.g., sumatriptan subcutaneous injection or nasal spray) 1, 2, 3
Specific Medication Options
Non-Oral Routes for Migraine Medications:
- Sumatriptan subcutaneous injection (6mg) - provides rapid relief and bypasses the GI tract 2, 3
- Sumatriptan nasal spray - alternative non-oral option 3
- Dihydroergotamine nasal spray - effective for acute treatment with non-oral administration 4
Antiemetic Options:
- Metoclopramide - treats nausea and improves gastric motility which may be impaired during migraine attacks 1, 5
- Prochlorperazine - can effectively relieve both headache pain and nausea 1, 6
Evidence-Based Considerations
Efficacy of Non-Oral Routes
- Subcutaneous sumatriptan demonstrates rapid onset of action, with headache response rates of 61-70% at 2 hours 3
- Dihydroergotamine nasal spray shows significant headache response at 4 hours compared to placebo (47-70% vs 22-35%) 4
Antiemetic Benefits
- Adding metoclopramide 10mg to aspirin significantly reduces nausea (p<0.00006) and vomiting (p=0.002) compared with aspirin alone 5
- Antiemetics should not be restricted to patients who are vomiting, as nausea itself is one of the most disabling symptoms of migraine 1
Important Considerations and Caveats
- Oral medications may have delayed absorption due to gastroparesis that often accompanies migraine attacks 1, 2
- Triptans should be avoided in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 1, 7
- Limit acute treatments to no more than twice weekly to prevent medication overuse headache 1, 2
- NSAIDs alone have limited efficacy for severe migraines, with naproxen showing an NNT of 11 for pain-free response at 2 hours 8
Special Populations
- For pregnant patients with migraines and nausea, acetaminophen is the safest option, though its efficacy alone for migraine is limited 9, 10
- For patients with contraindications to triptans, antiemetics like prochlorperazine or metoclopramide can provide both anti-nausea and antimigraine effects 6, 10