The Role Of Antiemetics In Migraine Therapy: Addressing Nausea And Vomiting In Migraine Attacks

  • Priyanka ThakurBachelor in Medicine, Bachelor in Surgery (MBBS), DRPGMC, India
  • Regina LopesSenior Nursing Assistant, Health and Social Care, The Open University

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Overview

Migraines affect individuals differently. Some individuals experience migraine attacks that last four hours, while others suffer up to three days. The pain can be severe enough to be disabling, forcing people to miss work and other daily activities. Migraines have wide-reaching effects that are not just limited to the person with migraine.

In the UK, an estimated 43 million days of work and education are lost due to migraine. Part of this can be attributed to the debilitating nature of nausea and vomiting that often accompany migraines. Luckily, medications are available that can be used to help manage these symptoms.1

What is a migraine?

Migraine is a painful condition that can recur on a long-term basis. A migraine attack normally feels like a severe headache with throbbing on one side of the head. However, migraines are more than just a simple headache. With migraines, the headaches can cause pain that is severe enough to disrupt daily activities.2

It is thought that migraines occur due to abnormal brain activity that affects the way signals are communicated in the brain. The cause of these activities is not well understood. However, some people find that certain triggers (e.g. food, smells, stress) can cause a migraine attack.3,4

What are the symptoms of migraine?

Migraines are associated with other characteristic symptoms that differentiate them from normal headaches. There are also defined stages to a migraine attack that do not occur with a normal headache.

Pre-migraine symptoms

Before a migraine headache starts, some people may experience a phase of warning symptoms that can begin as early as three days prior. Symptoms include feeling tired, changes in mood, neck pain and sensitivity to light. These have been linked to the hypothalamus – the part of the brain that controls emotions and sensations. The autonomic nervous system can also be affected, which causes symptoms that we are unable to consciously control, such as nausea and vomiting, thirst, watery eyes and runny nose.4

Aura

You may have heard of migraine aura. Not all migraines are associated with auras, but approximately a third of migraine attacks are preceded by an aura.4

Migraine auras are symptoms that can occur with or without migraine headaches. They are normally fully reversible, develop quickly over a few minutes and last up to an hour. Examples of these disturbances include:2,3,4

  • Visual disturbances that can range from unusual sensitivity to light, seeing flickering lights, spots or lines in vision, and even partial loss of vision. Double vision is a rare but unusual symptom that may require further investigation
  • Sensory disturbances including pins and needles, numbness, tinnitus, vertigo and nausea
  • Speech disturbances such as inability to speak clearly and slurred speech
  • Motor disturbances including muscle weakness – which may require further medical attention

Migraine headache

Typical migraine headaches are felt as a severe pain that pulsates from one side of the head. This throbbing pain comes from pain signals stimulating different parts of the brain. As the migraine progresses, nerve cells inside the brain become sensitive to different stimuli.

The brain becomes more responsive to pain signals and can cause other symptoms like a tender scalp or sensitivity to touch. Migraine can be aggravated by routine activities, which disrupts daily life for many sufferers.2,4

On the other hand, compared to migraine headaches, tension headaches can feel like mild pain tightening in a band around the head. There is little pulsating pain, and the headache normally clears up after a couple of hours without affecting daily living.2

Nausea and vomiting

Nausea and vomiting are important protective mechanisms that prevent us from digesting harmful substances and consuming matters that could be toxic. However, severe vomiting can become harmful as it can lead to dehydration, particularly if ongoing. Although not all migraines come with nausea, when it does occur, the sensation of nausea can be highly debilitating, to the point that it affects daily life.

Migraines that are accompanied by nausea and vomiting are associated with reduced productivity and an inability to carry out usual daily activities. Additionally, vomiting can also hinder the effectiveness of certain treatments. For example, it becomes harder to retain medications like tablets and capsules after swallowing them.

This makes it more challenging to recover from a migraine attack. Finally, nausea and vomiting make it more difficult to get a good night’s sleep, which impacts mental health and daily functioning.5

Nausea and vomiting are a huge burden that comes along with migraines. Anti-nausea medications are available to help manage these symptoms.

What are antiemetics?

Antiemetics are anti-nausea medications or anti-sickness medications. There are many types of antiemetics that work in different ways. In the UK, there are currently no medicines that are specifically licensed for nausea and vomiting in migraine. However, there are three main antiemetics that can be considered for use in treating nausea and vomiting in migraines. These include metoclopramide, prochlorperazine and domperidone.2

These antiemetics work by blocking dopamine receptors in the brain and preventing dopamine from binding to them. Dopamine is a neurotransmitter, which means that it is a chemical that binds to receptors and allows communication in the brain. Dopamine has been linked to the mechanism of nausea, although the exact way it works is unclear. By blocking dopamine from binding to its receptor, these antiemetics alleviate nausea in migraines.6

What is the role of antiemetics in migraine therapy?

The main players in migraine therapy include medications that alleviate pain, including paracetamol and non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen. Triptans (e.g. sumatriptan and rizatriptan) are another class of medications that cause the release of compounds that directly alleviate migraine.2

Antiemetics play a supportive role, in that they are mainly used as an add-on that acts on severe symptoms of nausea and vomiting. Metoclopramide may be used in combination with pain medication and improve the absorption of the pain medication.2,7

How should antiemetic drugs be taken?

Metoclopramide and domperidone are available as a tablet or a liquid. In most adults, the recommended dose is 10mg up to three times a day for both medications. Domperidone should be taken at least half an hour before food, otherwise absorption of the medication could be delayed.7

Prochlorperazine is available as a tablet that is swallowed, and as a buccal tablet that can be held between the gum and cheek and left to dissolve.7

What are the main side effects of antiemetics used in migraine therapy?

Metoclopramide, prochlorperazine and domperidone all act on dopamine receptors. However, in addition to nausea and vomiting, there are numerous other processes that are controlled by the dopamine pathway. These include:

  • Dystonia Dystonia is a type of movement disorder involving uncontrolled spasms or tremors that may be painful. One idea about why this happens is that long-term exposure to the dopamine-blocking antiemetic can make the brain more sensitive to dopamine. Dystonia is more likely to happen in younger adults and the very old2,7
  • Drowsiness – Antiemetics used for nausea in migraines tend to make the people taking them feel sleepy. Due to the potential impact on vision and alertness, it is recommended to avoid driving or operating heavy machinery. The sedative effect can also be worsened if alcohol is consumed at the same time7

These side effects are normally completely reversible once the treatment is no longer being taken. Metoclopramide and domperidone in particular, are not normally taken long-term. As a precaution, individuals may be prescribed small amounts of antiemetics at a time. If these medications have been taken regularly for a long time, it is not recommended to stop taking the medications without supervision from the prescriber, as suddenly stopping them can make the individual feel very poorly.2

Summary

Due to the severity and unpleasantness of symptoms, migraines are distressing for millions. In some people, migraines also bring nausea and vomiting which adds to their challenge. In the UK, there are currently three antiemetic medications that are used as an add-on in migraine therapy to relieve migraine-related nausea. Metoclopramide, prochlorperazine and domperidone work by blocking dopamine receptors in the brain and alleviating associated nausea.

References

  1. The Migraine Trust [Internet]. [cited 2024 May 9]. Impact of migraine. Available from: https://migrainetrust.org/understand-migraine/impact-of-migraine/
  2. NICE [Internet]. 2012 [cited 2024 May 9]. Headaches in over 12s: diagnosis and management. Available from: https://www.nice.org.uk/guidance/cg150/chapter/Recommendations
  3. Charles A. The pathophysiology of migraine: implications for clinical management. The Lancet Neurology [Internet]. 2018 Feb [cited 2024 May 9];17(2):174–82. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1474442217304350
  4. Dodick DW. A phase‐by‐phase review of migraine pathophysiology. Headache [Internet]. 2018 May [cited 2024 May 9];58(S1):4–16. Available from: https://headachejournal.onlinelibrary.wiley.com/doi/10.1111/head.13300
  5. Gajria K, Lee LK, Flores NM, Aycardi E, Gandhi SK. Humanistic and economic burden of nausea and vomiting among migraine sufferers. Journal of Pain Research [Internet]. 2017 Mar;10:689–98. Available from: https://www.tandfonline.com/doi/full/10.2147/JPR.S124683
  6. Belkacemi L, Darmani NA. Dopamine receptors in emesis: Molecular mechanisms and potential therapeutic function. Pharmacological Research [Internet]. 2020 Nov [cited 2024 May 9];161:105124. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1043661820314328
  7. NICE [Internet]. BMJ; [cited 2024 May 9]. BNF. Available from: https://bnf.nice.org.uk/

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This content is purely informational and isn’t medical guidance. It shouldn’t replace professional medical counsel. Always consult your physician regarding treatment risks and benefits. See our editorial standards for more details.

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