Migraine Headache
Migraine is the type of headache that characteristically improves after vomiting, though the mechanism remains incompletely understood. 1
Clinical Characteristics
- Vomiting has been reported by migraine patients to be therapeutic and may actually stop a migraine attack, distinguishing migraine from other headache types 1
- Nausea and vomiting affect at least 60% of migraine patients during attacks, and these symptoms are often more disabling than the headache itself 2
- The relief from vomiting appears related to complex interactions between the enteric nervous system, autonomic nervous system, and central nervous system 1
Important Clinical Context
- While vomiting may provide relief, it significantly complicates treatment by delaying or interfering with oral medication absorption 2
- When significant nausea or vomiting is present early in a migraine attack, non-oral routes of administration should be selected 3, 4
- The presence of nausea and vomiting warrants antiemetic treatment, as nausea itself is one of the most disabling symptoms of migraine, not just the vomiting 5
Treatment Implications
- Metoclopramide provides both antiemetic effects and synergistic analgesia for migraine pain, making it particularly useful when nausea/vomiting is prominent 4, 5
- Subcutaneous sumatriptan (6 mg) or intranasal formulations are preferred when vomiting is present, as they bypass the gastrointestinal tract 4
- The goal is to stop the migraine attack as quickly as possible with effective drugs at effective doses, using alternative routes when oral administration is compromised 2
Critical Pitfall to Avoid
- Do not restrict antiemetic treatment only to patients who are actively vomiting—nausea itself warrants treatment as it is highly disabling and interferes with oral medication efficacy 5