The route of administration is an important component of migraine therapy. Oral therapy is usually the first choice for most patients, and can be effective even if nausea and vomiting are associated with the migraine attack, provided that the oral route is initiated early in the migraine attack. Patients with severe vomiting may require non-oral treatment. The recent availability of an intranasal preparation of sumatriptan and DHE has expanded parenteral treatment options. For severe migraines, subcutaneous injections may be the most appropriate choice, followed by intranasal preparations or rectal suppositories.
Oral preparations have the slowest onset of action.
Consider an anti-emetic agent only in patients whose nausea and vomiting are not relieved by specific migraine therapy Nausea and vomiting are common accompaniments of migraine headache and can be as disabling as the headache itself. In the instances where the patient continues to experience nausea and vomiting, an antiemetic agent can be prescribed. The use of abortive medication more than twice a week Special circumstances, such as hemiplegic migraine or rare headache attacks producing profound disruption or risk of permanent neurological injury. Choice of treatment is empiric in nature, driven in part by patient preferences and comorbidities. A trial of prophylactic therapy should start with a low dose of medication, slowly escalating until a treatment effect or ceiling dose is achieved.