Use of dopamine antagonists in treatment of migraine.

OPINION STATEMENT: Dopamine antagonists are indicated for treatment of nausea or psychosis and have an established role in the treatment of migraine. Neuroleptics, including antipsychotics, act as antagonists at the dopamine D2 receptor type. These medications also have variable activity as antihistamines and anticholinergics, and they block alpha-adrenergic and some serotonin receptor types, but their actions on dopamine are likely the reason for their efficacy in treating nausea, psychosis, and acute migraine. Neuroleptics are first-line agents in the emergency room setting for migraine, especially for patients with nausea and vomiting. In the setting of a clear prodrome, antiemetics may prevent migraine when taken before an attack. They are also indicated in clinical situations such as patients who are pregnant or have contraindications to migraine-specific medications or NSAIDs. Recent developments suggest that dopamine is particularly important in chronic pain, and we most commonly use neuroleptic medications in the treatment of status migrainosus or medication-overuse headache. Clinicians may avoid dopamine antagonists because of unfamiliarity and a lack of large, controlled clinical trials. Their use requires special care to avoid adverse events such as sedation, akathisia or dystonic reactions, neuroleptic malignant syndrome, or movement disorders with long-term use. Some newer atypical neuroleptic agents appear promising for both acute and prophylactic migraine treatment with a lower risk of adverse events.