Management of Migraine with Vomiting
For migraine with significant vomiting, use a non-oral route of administration immediately—specifically intranasal sumatriptan 5-20 mg or IV metoclopramide 10 mg plus IV ketorolac 30 mg—rather than attempting oral therapy that will not be absorbed. 1, 2
Immediate Treatment Algorithm
When Vomiting is Present Early in the Attack
Select non-oral administration as first-line therapy when nausea or vomiting present early as significant components of migraine attacks, as oral medications will have impaired absorption 1
Intranasal sumatriptan (5-20 mg) provides rapid relief with onset within 15 minutes and is the most effective non-oral option for patients who cannot tolerate oral medications due to vomiting 2, 3
Subcutaneous sumatriptan 6 mg achieves the highest efficacy among all triptan formulations, with 59% achieving complete pain relief by 2 hours and onset of action within 15 minutes 1, 2, 4
IV Treatment for Severe Attacks with Vomiting
Metoclopramide 10 mg IV plus ketorolac 30 mg IV represents first-line combination therapy for severe migraine requiring intravenous treatment, providing both direct analgesic effects and antiemetic properties 2, 5
Metoclopramide provides synergistic analgesia for migraine pain through central dopamine receptor antagonism, not just antiemetic effects 2, 6
Ketorolac has rapid onset with approximately 6 hours duration and minimal rebound headache risk 2
Antiemetic Therapy is Essential
Treat nausea itself, not just vomiting, as nausea is one of the most disabling symptoms of migraine and warrants treatment even without active vomiting 2, 6
Antiemetics should be given 20-30 minutes before analgesics when possible to enhance absorption of co-administered medications 2, 7
Metoclopramide significantly reduces both nausea (P < 0.00006) and vomiting (P = 0.002) compared to analgesics alone 8
Critical Contraindications to Assess
Do not use triptans in patients with uncontrolled hypertension, ischemic heart disease, cerebrovascular disease, basilar or hemiplegic migraine, or Wolff-Parkinson-White syndrome 1, 4, 9
Perform cardiovascular evaluation in triptan-naive patients with multiple cardiovascular risk factors (increased age, diabetes, hypertension, smoking, obesity, strong family history of CAD) before prescribing triptans 4
Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 2
Medication Overuse Prevention
Strictly limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which can lead to daily headaches and treatment resistance 1, 2, 10
If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing acute medication frequency 1, 2
Medication overuse headache can develop from frequent use of triptans (≥10 days/month), NSAIDs (≥15 days/month), or combination analgesics 2, 4
Alternative Options When First-Line Fails
Try a different triptan if one fails after 2-3 headache episodes, as failure of one triptan does not predict failure of others 2
Rizatriptan 10 mg reaches peak concentration in 60-90 minutes, making it the fastest oral triptan for future episodes when vomiting is not present 2
Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy when triptans are contraindicated or ineffective 1, 2
When to Escalate to Preventive Therapy
Initiate preventive therapy for patients with two or more attacks per month producing disability for 3+ days, or when acute medications are needed more than twice weekly 1, 2
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 1