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.