What is the best treatment for vomiting from migraine headache in a pediatric patient?

Treatment of Vomiting from Migraine in a 7-Year-Old

For a 7-year-old with migraine-associated vomiting, ibuprofen 7.5-10 mg/kg should be given as first-line treatment, with domperidone as an adjunct antiemetic if the child can still take oral medication, or consider intranasal sumatriptan (5-20 mg) if oral route is not feasible due to severe nausiting. 1, 2

First-Line Acute Treatment Approach

Oral Route (If Child Can Tolerate)

• Ibuprofen at 7.5-10 mg/kg is the recommended first-line medication for pediatric migraine, as it is both safe and effective in this age group 2
• Administer the medication as early as possible at the onset of headache symptoms, ideally when pain is still mild, as early treatment improves efficacy 1
• Acetaminophen 15 mg/kg is an alternative if ibuprofen is contraindicated, though ibuprofen has stronger evidence in pediatric migraine 2

Managing the Nausea and Vomiting Component

• Domperidone is recommended as an adjunct oral medication for nausea and vomiting in children with migraine 1
• The antiemetic should be given 20-30 minutes before the analgesic when possible, as it helps overcome gastric stasis and improves absorption of the pain medication 3
• Important caveat: Domperidone is approved for adolescents aged 12-17 years according to formal guidelines, but is used in younger children in clinical practice under specialist supervision 1

When Oral Route Fails

Non-Oral Alternatives

• Intranasal sumatriptan (5-20 mg) is the most effective non-oral option for children who cannot tolerate oral medications due to vomiting 1, 4
• Sumatriptan nasal spray has demonstrated efficacy in pediatric populations and should be considered when the oral route is compromised 2
• Rectal routes can be used for both analgesics and antiemetics when nausea or vomiting prevents oral administration 5

Critical Timing Consideration

• Bed rest alone may suffice in children with short-duration attacks, which are common in this age group 1
• Sleep often terminates pediatric migraine attacks naturally, so creating a quiet, dark environment is an important adjunct 5

Important Clinical Pitfalls to Avoid

Medication Overuse

• Limit acute medication use to no more than twice weekly to prevent medication-overuse headache, which can develop even in children 1
• If the child requires treatment more than 2 days per week, preventive therapy should be considered rather than increasing acute medication frequency 1

Age-Specific Considerations

• Migraine attacks in children are often shorter (2-72 hours), more bilateral, and have prominent gastrointestinal symptoms compared to adults 1
• The headache may be frontal rather than unilateral in two-thirds of pediatric cases 5
• Vomiting may be more disabling than the headache itself in children, making antiemetic treatment particularly important 6, 5

When to Escalate Care

Indications for Specialist Referral

• If acute medication provides insufficient pain relief after adequate trials of both ibuprofen and intranasal sumatriptan, referral to specialist care is indicated 1
• Consider preventive therapy consultation if attacks occur more than 2 days per month and continue to impair quality of life despite optimized acute treatment 1

Non-Pharmacological Measures

• Identify and avoid trigger factors such as emotional stress, hypoglycemia, lack of sleep or excess sleep, and sensory stimulation 5
• Ensure regular meals, adequate hydration, and consistent sleep schedules 1
• Education of both parents and teachers is necessary for effective management in this age group 1