Treatment of Nausea and Vomiting from Tension Headaches
For nausea and vomiting associated with tension headaches, treat the underlying headache with NSAIDs (ibuprofen 400-800 mg or naproxen 500-825 mg) as first-line therapy, and add metoclopramide 10 mg orally or IV if nausea is disabling, limiting use to no more than twice weekly to prevent medication-overuse headache. 1
Critical Distinction: Tension vs. Migraine Headaches
The evidence provided predominantly addresses migraine-associated nausea and vomiting, not tension headaches. This is an important clinical distinction because:
- Tension headaches rarely cause nausea and vomiting 2
- Tension headaches present as a constant, tight, pressing, or bandlike sensation without the throbbing quality of migraine 2
- If significant nausea and vomiting are present with headache, reconsider the diagnosis—this likely represents migraine, not tension headache 2
First-Line Treatment Algorithm
Step 1: Treat the Headache Itself
- Start with NSAIDs as primary therapy: ibuprofen 400-800 mg or naproxen sodium 500-825 mg at headache onset 1, 3
- NSAIDs address both the headache pain and can reduce associated nausea 3
- Alternative option: acetaminophen 1000 mg if NSAIDs are contraindicated 3
Step 2: Add Antiemetic Only If Nausea Is Disabling
- Metoclopramide 10 mg (oral or IV) provides both antiemetic effects and synergistic analgesia 1, 4
- Give antiemetic 15-20 minutes before the analgesic to enhance absorption 3
- Alternative: prochlorperazine 10 mg IV or 25 mg orally if metoclopramide is contraindicated 1
Step 3: Consider Non-Oral Routes If Vomiting Is Present
- If vomiting prevents oral medication absorption, use rectal suppositories (acetaminophen 1000 mg or metoclopramide 20 mg suppository) 3
- IV metoclopramide 10 mg is highly effective when oral route is not feasible 1
Critical Frequency Limitation
Restrict all acute 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
Important Contraindications and Precautions
Metoclopramide Contraindications:
- Pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 1
- Monitor for akathisia (restlessness) which can develop within 48 hours of administration 6
NSAID Contraindications:
- Renal impairment (creatinine clearance <30 mL/min), active GI bleeding, or aspirin/NSAID-induced asthma 1
When to Escalate or Reconsider Diagnosis
If nausea and vomiting persist despite this approach:
- Reassess the diagnosis: Significant nausea/vomiting with headache strongly suggests migraine rather than tension headache 2
- If migraine is confirmed, escalate to triptan therapy (sumatriptan 50-100 mg) combined with NSAID 1
- Initiate preventive therapy if headaches occur more than 2 days per week 5
Common Pitfall to Avoid
Do not allow escalation of acute medication frequency in response to persistent symptoms—this creates medication-overuse headache. Instead, transition to preventive therapy while optimizing the acute treatment strategy 1, 5