Optimal management of severe nausea and vomiting in migraine: improving patient outcomes

Abstract

Migraine is a common and potentially disabling disorder for patients, with wide-reaching implications for health care services, society, and the economy. Nausea and vomiting during migraine attacks are common symptoms that affect at least 60% of patients suffering from migraines. These symptoms are often more disabling than the headache itself, causing a great burden on the patient’s life. Nausea and vomiting may delay the use of oral abortive medication or interfere with oral drug absorption. Therefore, they can hinder significantly the management and treatment of migraine (which is usually given orally). The main treatment of pain-associated symptoms of migraine (such as nausea and vomiting) is to stop the migraine attack itself as soon as possible, with the effective drugs at the effective doses, seeking if necessary alternative routes of administration. In some cases, intravenous antiemetic drugs are able to relieve a migraine attack and associated symptoms like nausea and vomiting. We performed an exhaustive PubMed search of the English literature to find studies about management of migraine and its associated symptoms. Search terms were migraine, nausea, and vomiting. We did not limit our search to a specific time period. We focused on clinical efficacy and tolerance of the various drugs and procedures based on data from human studies. We included the best available studies for each discussed drug or procedure. These ranged from randomized controlled trials for some treatments to small case series for others. Recently updated books and manuals on neurology and headache were also consulted. We herein review the efficacy of the different approaches in order to manage nausea and vomiting for migraine patents.

A Phase I, Open‐Label, Single‐Dose Safety, Pharmacokinetic, and Tolerability Study of the Sumatriptan Iontophoretic Transdermal System in Adolescent Migraine Patients

“…The use of oral medications is often limited by nausea. Furthermore, oral medications are affected by decreased gastrointestinal motility that happens during migraine attacks, with a consequent impact on the bioavailability of the drug . Delivery of sumatriptan by transdermal patch circumvents this challenge by avoiding the gastrointestinal tract …”

“…Furthermore, oral medications are affected by decreased gastrointestinal motility that happens during migraine attacks, with a consequent impact on the bioavailability of the drug. 21 Delivery of sumatriptan by transdermal patch circumvents this challenge by avoiding the gastrointestinal tract. 21 A key concept in the acute treatment of migraine includes identifying the proper triptan for proper patients, and once the proper triptan is identified, matching the formulation with patient needs, since each triptan or formulation is associated with specific advantages and disadvantages.…”

“…21 Delivery of sumatriptan by transdermal patch circumvents this challenge by avoiding the gastrointestinal tract. 21 A key concept in the acute treatment of migraine includes identifying the proper triptan for proper patients, and once the proper triptan is identified, matching the formulation with patient needs, since each triptan or formulation is associated with specific advantages and disadvantages. 22 Based on its delivery method, the iontophoretic TDS avoids many of the disadvantages associated with other forms of migraine drug delivery.…”

Headache in Children and Adolescents

“…85 Adjunctive medications to treat nausea 86 and anxiety 87 may be added if needed. Due to the paucity of controlled trials in this area, variation from the experts exists on when to institute over-the-counter drugs (such as ibuprofen 88 and acetaminophen 89 ), and when to use the migraine-specific triptans.…”

Enhanced pharmacological efficacy of sumatriptan due to modification of its physicochemical properties by inclusion in selected cyclodextrins

“…5-HT 1F receptors and calcitonin-gene-related peptide (CGRP) receptors; however, despite this, the superiority of sumatriptan over placebos in the attenuation of headache, nausea, photophobia, and phonophobia in migraineurs is still not well-established. Although of the triptans sumatriptan demonstrates the strongest antiemetic action, an advantage in the treatment of migraine with vomiting 3 , it has the lowest bioavailability, which is a limitation to the achievement of a greater pharmacological effect 4 . Another problem is the bitter taste of sumatriptan that has not been eliminated by the conversion of the compound to a succinate ester, a form found in commercially available pharmaceutical preparations 5 .…”