How should I treat a 22‑year‑old woman with acute migraine, associated nausea, vomiting, diarrhea, mild abdominal pain, and documented hypomagnesemia?

Acute Migraine with Hypomagnesemia and GI Symptoms

For this 22-year-old woman with acute migraine, nausea, vomiting, diarrhea, and documented hypomagnesemia who has already received IV magnesium and standard IV headache medications without relief, the next step is IV metoclopramide 10 mg plus IV ketorolac 30 mg as combination therapy, followed by consideration of IV dihydroergotamine if this fails. 1

Immediate IV Treatment Strategy

• IV metoclopramide 10 mg plus IV ketorolac 30 mg represents the most evidence-based first-line IV combination for severe migraine requiring emergency treatment, providing both direct analgesic effects and synergistic pain relief while minimizing rebound headache risk. 1

• Metoclopramide provides independent analgesic benefit through central dopamine receptor antagonism—not merely antiemetic effects—and its prokinetic action helps overcome gastric stasis during migraine attacks. 1

• Ketorolac has rapid onset with approximately 6 hours of duration and minimal rebound headache risk, making it ideal for severe migraine abortive therapy. 1

• If the metoclopramide-ketorolac combination fails after 1–2 hours, escalate to IV dihydroergotamine (DHE) 0.5–1.0 mg, which has good evidence for efficacy as monotherapy for acute migraine. 1

Role of Magnesium in This Case

• While IV magnesium sulfate 1 g demonstrates efficacy in acute migraine treatment (with 87% pain-free rates in controlled trials), the fact that this patient has already received IV magnesium without relief suggests either inadequate dosing, timing issues, or that her migraine is not primarily magnesium-responsive. 2, 3

• Documented hypomagnesemia should still be corrected with additional IV magnesium replacement (typically 2 g total over 24 hours), but this is now a metabolic correction rather than acute migraine therapy. 4, 5

• The presence of diarrhea may indicate ongoing magnesium losses and warrants investigation of the underlying cause (malabsorption, renal wasting, or dietary deficiency). 4

Management of GI Symptoms

• The combination of nausea, vomiting, and diarrhea with migraine may represent abdominal migraine or migraine-associated GI dysfunction, which responds to the same acute treatments as cranial migraine. 6

• Metoclopramide addresses both the nausea and the migraine pain itself, making it particularly appropriate for this presentation. 1

• Mild abdominal pain in the context of migraine with GI symptoms does not require separate evaluation unless red-flag features develop (fever, peritoneal signs, bloody diarrhea suggesting mesenteric ischemia). 7

Critical Medication Frequency Limits

• All acute migraine medications must be limited to ≤2 days per week (≤10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1

• If this patient requires acute treatment more than twice weekly, immediate initiation of preventive therapy is mandatory rather than increasing acute medication frequency. 1

Contraindications and Safety Considerations

• Metoclopramide is contraindicated in pheochromocytoma, seizure disorders, GI bleeding, and GI obstruction—none of which are suggested by this presentation. 1

• Ketorolac should be used cautiously if there is any history of renal impairment, GI bleeding, or significant cardiovascular disease. 1

• DHE is contraindicated if triptans have been used in the past 24 hours, in uncontrolled hypertension, coronary artery disease, pregnancy, or sepsis. 1

Medications to Avoid

• Opioids (hydromorphone, morphine, codeine) are absolutely contraindicated for migraine treatment due to questionable efficacy, high dependency risk, rebound headaches, and worsening long-term outcomes. 1

• Butalbital-containing compounds should be avoided due to high medication-overuse headache risk and limited efficacy. 1

Disposition and Follow-Up

• If IV combination therapy achieves pain relief, discharge with oral preventive therapy counseling and strict instructions to limit acute medication use to ≤2 days per week. 1

• If all IV therapies fail (metoclopramide + ketorolac, then DHE), consider admission for status migrainosus management with continuous DHE infusion or greater occipital nerve block. 1

• Schedule neurology follow-up within 1–2 weeks to initiate preventive therapy (first-line options: propranolol 80–240 mg/day, topiramate, or amitriptyline) and address the underlying hypomagnesemia with oral magnesium supplementation 400–600 mg daily. 1, 4