What is the first line treatment for a 7-year-old with migraines (headaches with neurological symptoms) experiencing vomiting at home?

Home Treatment for Vomiting in a 7-Year-Old with Migraines

For a 7-year-old experiencing vomiting during a migraine attack at home, administer ibuprofen 10 mg/kg orally at the first sign of symptoms, and if vomiting prevents oral medication, switch immediately to a non-oral route such as intranasal sumatriptan or rectal ibuprofen. 1

First-Line Oral Treatment Strategy

• Ibuprofen 10 mg/kg should be given at the earliest onset of migraine symptoms, ideally before vomiting begins, as NSAIDs are first-line treatment for pediatric migraine and early administration is critical for efficacy 2, 1
• The medication should be taken when the headache is still mild, as effectiveness depends on timely use with the correct dose 2
• Acetaminophen alone is ineffective for migraine and should not be used 2

When Vomiting Prevents Oral Medication

• Switch to non-oral routes immediately when nausea or vomiting occurs early in the attack, as oral medications cannot be absorbed effectively 2, 1
• Intranasal sumatriptan (5-20 mg) is the preferred alternative route for moderate to severe attacks when significant nausea or vomiting is present 3
• Rectal ibuprofen is another option when the nasal route is not available 1

Antiemetic Adjunct Therapy

• Prokinetic antiemetics such as metoclopramide or domperidone should be used as adjunct medications for nausea and vomiting during migraine attacks 2
• These medications provide both antiemetic effects and synergistic analgesia for migraine pain 3
• Metoclopramide also enhances absorption of co-administered oral medications by overcoming gastric stasis 3

Critical Timing Considerations

• The single most important factor is early administration - waiting until vomiting is established significantly reduces treatment effectiveness 2, 1
• Parents should be instructed to give medication at the very first sign of migraine symptoms (visual changes, mood changes, or mild headache onset) rather than waiting for severe pain or vomiting 2
• Sleep often ends pediatric migraine attacks, so creating a quiet, dark environment after medication administration is beneficial 1

Common Pitfall to Avoid

• Do not wait to see if the headache "gets better on its own" - this delay allows the attack to progress to the point where vomiting prevents oral medication absorption and the migraine becomes much harder to treat 2, 1
• Avoid frequent repeated use of acute medications (more than twice weekly), as this risks development of medication-overuse headache 2

When to Consider Preventive Therapy

• If the child experiences two or more migraine attacks per month with disability lasting 3 or more days, or if acute medications are needed more than twice weekly, preventive therapy should be considered 2, 4
• Non-pharmacological treatments including biofeedback and progressive muscle relaxation have shown good efficacy as prophylactic measures in children 1