What is the best course of treatment for a patient presenting with headache and vomiting?

Headache with Vomiting: Treatment Approach

For a patient presenting with headache and vomiting, first rule out life-threatening secondary causes (meningitis, subarachnoid hemorrhage, intracranial lesion), then treat as acute migraine with IV metoclopramide 10 mg plus IV ketorolac 30 mg, which provides both direct analgesic effects and antiemetic control while minimizing rebound headache risk. 1

Step 1: Immediate Red Flag Assessment

Before initiating treatment, rapidly screen for secondary headache warning signs that require urgent neuroimaging or lumbar puncture 2:

• Thunderclap headache suggests subarachnoid hemorrhage 2
• Fever with neck stiffness indicates meningitis 2
• Focal neurological symptoms suggest intracranial pathology 2
• Progressive headache or altered consciousness indicates space-occupying lesion 2
• New onset headache >50 years warrants consideration of temporal arteritis 2

If any red flags are present, obtain emergent CT head and/or lumbar puncture before treating symptomatically. 2, 3

Step 2: First-Line IV Treatment for Acute Migraine with Vomiting

Once secondary causes are excluded, the optimal emergency treatment is 1:

• Metoclopramide 10 mg IV - provides direct analgesic effects through central dopamine receptor antagonism, independent of antiemetic properties 1, 4
• Ketorolac 30 mg IV - rapid onset with 6-hour duration and minimal rebound headache risk 1

This combination is superior to either agent alone and represents the strongest evidence-based recommendation for severe migraine with vomiting. 1

Critical Rationale for Non-Oral Route

When significant nausea or vomiting is present early in the attack, non-oral routes must be selected because gastric stasis impairs oral medication absorption. 4 The presence of vomiting indicates that oral medications will fail regardless of their intrinsic efficacy 2, 4.

Why Metoclopramide is Essential

Nausea itself warrants antiemetic treatment - it should not be restricted only to patients who are vomiting, as nausea is one of the most disabling symptoms of migraine. 2, 4 Metoclopramide provides synergistic analgesia beyond its antiemetic effects, making it particularly valuable when nausea/vomiting is prominent 4.

Step 3: Alternative IV Options

If metoclopramide is contraindicated (pheochromocytoma, seizure disorder, GI bleeding/obstruction, or CNS depression) 1:

• Prochlorperazine 10 mg IV - comparable efficacy to metoclopramide with 21% adverse event rate versus 50% for chlorpromazine 1
• Dihydroergotamine (DHE) IV or nasal spray - good evidence for efficacy as monotherapy 2, 1

Subcutaneous Option for Severe Cases

Subcutaneous sumatriptan 6 mg provides the most rapid and effective relief, with 70-82% achieving pain relief within 15 minutes and 59% achieving complete pain relief by 2 hours. 1 This route bypasses the GI tract entirely and reaches peak blood concentrations in approximately 15 minutes 1, 4.

However, sumatriptan is contraindicated in patients with ischemic heart disease, uncontrolled hypertension, Wolff-Parkinson-White syndrome, or history of stroke/TIA. 5

Step 4: Critical Safety Warnings

Metoclopramide Risks

Metoclopramide carries risk of tardive dyskinesia (TD), which increases with duration of treatment and total cumulative dose. 6, 7 Treatment longer than 12 weeks should be avoided in all but rare cases 6, 7. Acute dystonic reactions occur in approximately 1 in 500 patients, more frequently in patients <30 years of age 6, 7.

Neuroleptic malignant syndrome (NMS), though rare, is potentially fatal and requires immediate discontinuation of metoclopramide. 6, 7

Medication-Overuse Headache Prevention

Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 5 This applies to NSAIDs, triptans, antiemetics, and all acute treatments 2, 1.

If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than allowing continued frequent acute medication use. 1

Step 5: Avoid These Medications

Opioids should be avoided for migraine treatment as they have questionable efficacy, considerable adverse effects, risk of dependency, and can cause rebound headaches. 2, 1 They should only be considered when all other evidence-based treatments have failed or are contraindicated, sedation is not a concern, and abuse risk has been addressed 2, 1.

Oral ergot alkaloids are poorly effective and potentially toxic - they should not be used. 2

Barbiturates carry considerable adverse effects and dependency risk and should be avoided. 2

Step 6: Post-Treatment Monitoring and Follow-Up

After acute treatment 1:

• Monitor for 2-24 hours with basic physiological observations
• Provide clear discharge instructions about medication-overuse headache risk
• Refer to headache specialist/neurology, as lack of referral involves high rate of relapse and repeat ED visits 3

When to Initiate Preventive Therapy

Preventive therapy is indicated for patients with: 2, 1

• Two or more attacks per month producing disability lasting 3+ days
• Use of abortive medication more than twice per week
• Contraindication to or failure of acute treatments
• Uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-line preventive agents include propranolol 80-240 mg/day, timolol 20-30 mg/day, amitriptyline 30-150 mg/day, or divalproex sodium 500-1500 mg/day. 2