What is the best course of treatment for a patient experiencing symptoms of migraine headache and vomiting?

Treatment of Migraine with Headache and Vomiting

For a patient experiencing migraine with vomiting, start with a non-oral triptan (subcutaneous or intranasal sumatriptan) combined with an antiemetic (metoclopramide 10 mg IV or prochlorperazine 10 mg IV), as oral medications will be poorly absorbed due to gastric stasis during the attack. 1

Immediate Treatment Algorithm

First-Line: Non-Oral Route Required

When vomiting is present, bypass oral medications entirely:

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes and 59% complete pain relief by 2 hours 1
• Intranasal sumatriptan 5-20 mg is an alternative when injection is not feasible 1
• Add IV metoclopramide 10 mg for dual benefit: treats nausea/vomiting AND provides direct analgesic effects through central dopamine receptor antagonism 1, 2
• Alternative antiemetic: IV prochlorperazine 10 mg has comparable efficacy to metoclopramide with a favorable side effect profile 1, 2

Second-Line: If Triptans Contraindicated or Failed

• IV ketorolac 30 mg provides rapid onset with 6-hour duration and minimal rebound headache risk 2
• Dihydroergotamine (DHE) intranasal or IV has good evidence for efficacy as monotherapy 1, 2
• CGRP antagonists (gepants) such as rimegepant or ubrogepant for patients with cardiovascular contraindications to triptans 1

Critical Timing Consideration

• Begin treatment as early as possible during the attack, even before vomiting becomes severe, as effectiveness depends on timely intervention 1
• Vomiting delays oral medication absorption and worsens gastric stasis, making non-oral routes essential 3, 4

Medications to Absolutely Avoid

• Do NOT use opioids or butalbital for migraine treatment—they have questionable efficacy, cause dependency, trigger rebound headaches, and lead to loss of efficacy over time 1, 5
• Avoid oral ergot alkaloids due to poor effectiveness and potential toxicity 1

Optimal IV "Cocktail" for Severe Cases

For patients requiring emergency department treatment:

• Metoclopramide 10 mg IV PLUS ketorolac 30 mg IV provides synergistic analgesia with rapid pain relief while minimizing side effects and rebound headache risk 2
• This combination addresses both the headache pain and associated nausea/vomiting simultaneously 2

Medication Overuse Warning

• Limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache 1
• Threshold varies: ≥15 days/month with NSAIDs triggers medication overuse headache; ≥10 days/month with triptans 1
• If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1

Contraindications to Monitor

• Triptans are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, or significant cardiovascular disease 2
• Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 2
• Ketorolac should be used with caution in renal impairment, history of GI bleeding, or heart disease 2

When Oral Route Becomes Feasible

Once vomiting subsides and oral intake is tolerated:

• Triptan (sumatriptan 50-100 mg) PLUS naproxen sodium 500 mg provides superior efficacy compared to either agent alone 2
• This combination yields 130 more patients per 1000 achieving sustained pain relief at 48 hours 2
• Add acetaminophen 1000 mg if NSAIDs are contraindicated 1

Preventive Therapy Indication

• Consider preventive therapy if attacks occur ≥2 days per month with significant disability, or if acute medication overuse is developing 1, 6
• Preventive options include propranolol 80-240 mg/day, topiramate, or CGRP monoclonal antibodies, with efficacy assessed after 2-3 months for oral agents 1, 2