What is the diagnosis and treatment for headache with nausea?

Headache with Nausea: Diagnosis and Treatment

Diagnosis

Headache with nausea most commonly represents migraine, which affects approximately 12% of the population and is characterized by moderate to severe headache accompanied by nausea in at least 60% of cases. 1, 2, 3

Key Diagnostic Features of Migraine

• At least two of the following headache characteristics: unilateral location, throbbing character, worsening with routine activity, or moderate to severe intensity 1
• At least one associated symptom: nausea/vomiting or photophobia/phonophobia 1
• Duration: typically 4-72 hours if untreated 1

Critical Red Flags Requiring Urgent Evaluation

Before diagnosing primary headache, screen for dangerous secondary causes by evaluating for: 2, 4

• Abrupt onset ("thunderclap" headache)
• Age ≥50 years with new-onset headache
• Neurologic deficits on examination
• History of cancer or immunosuppression
• Provocation by physical activities or postural changes
• Fever with neck stiffness

If any red flags are present, neuroimaging and further workup are mandatory before treating as primary headache. 4, 5

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Acute Treatment Algorithm

For Mild to Moderate Migraine with Nausea

First-line treatment is NSAIDs combined with an antiemetic, using non-oral routes when nausea is prominent. 1, 6, 7

Specific regimen:

• NSAIDs: Naproxen sodium 500-825 mg OR ibuprofen 400-800 mg (oral if tolerated, or ketorolac 30-60 mg IM/IV if oral route compromised) 8, 7
• Plus antiemetic: Metoclopramide 10 mg IV OR prochlorperazine 10 mg IV 6, 8

Rationale: Nausea itself is one of the most aversive and disabling symptoms of migraine and should be treated directly, not just when vomiting occurs. 1, 6 Antiemetics also provide synergistic analgesia for migraine pain and improve gastric motility, enhancing absorption of oral medications. 6, 8

For Moderate to Severe Migraine with Nausea

Use migraine-specific agents via non-oral routes when nausea is significant. 1, 7

Preferred options:

• Sumatriptan subcutaneous 6 mg (highest efficacy: 59% pain-free at 2 hours, 79% at 4 hours) 9
• Sumatriptan nasal spray 5-20 mg 7, 9
• Alternative triptans: rizatriptan, zolmitriptan, or naratriptan (oral if nausea not severe) 1, 9

Plus antiemetic:

• Metoclopramide 10 mg IV OR prochlorperazine 10 mg IV 6, 8

Critical contraindications to triptans: uncontrolled hypertension, cardiovascular disease, hemiplegic or basilar migraine 7, 2

For Severe Migraine Requiring IV Treatment

Recommended IV combination ("headache cocktail"): 8

• Ketorolac 30 mg IV (60 mg IM if <65 years old)
• Plus metoclopramide 10 mg IV OR prochlorperazine 10 mg IV
• Consider adding: Dexamethasone to reduce headache recurrence 10

Alternative for triptan-contraindicated patients: Dihydroergotamine (DHE) 0.5-1 mg IV/IM or intranasal 1, 8, 7

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Critical Treatment Principles

Timing and Route Selection

• Treat as early as possible during the attack to maximize efficacy 8, 7
• Select non-oral routes when nausea/vomiting are prominent due to gastroparesis that impairs oral medication absorption 1, 7
• Do not wait for vomiting to treat nausea—nausea alone warrants antiemetic therapy 1, 6

Medication Overuse Prevention

Limit acute medications to no more than 2 days per week to prevent medication-overuse headache, which creates a vicious cycle of increasing headache frequency. 1, 8, 7 If patients require acute treatment more frequently, transition to preventive therapy. 1, 8

When to Initiate Preventive Therapy

Consider preventive medications when: 1

• ≥2 attacks per month producing disability lasting ≥3 days
• Acute treatments fail or are contraindicated
• Acute medications used >2 times per week
• Presence of chronic migraine (≥15 headache days per month for ≥3 months, with ≥8 meeting migraine criteria) 1

First-line preventive agents: propranolol 80-240 mg/day, amitriptyline 30-150 mg/day, or divalproex sodium 500-1500 mg/day 1, 7

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Common Pitfalls to Avoid

1. Using acetaminophen alone—there is no evidence for efficacy in migraine 1
2. Restricting antiemetics only to vomiting patients—nausea itself is disabling and requires treatment 1, 6
3. Delaying treatment until pain is severe—early treatment is more effective 8, 7
4. Prescribing opioids routinely—these should be reserved only when other treatments fail, sedation is acceptable, and abuse risk is addressed, as they lead to medication-overuse headache and dependency 8, 7
5. Allowing escalating frequency of acute medication use—this creates medication-overuse headache; instead, initiate preventive therapy 8