My wife's migraines come with hours of v

The line to watch is not how long the pain lasts — it is whether she can keep fluids down: the moment she cannot keep water down, that is a go-now decision, not a "let's see how the night goes". Last time you reached that point after twelve hours; this time, treat that moment as the trigger instead of the end of the wait.

Here is the tree, in three lines:

Which country and city are you in? I don't hold emergency numbers for any country in memory, so I have no coverage for your local emergency number, your urgent-care route, or what her pharmacist can supply until you tell me the place — and if you tell me, I can bring up the correct one. Say it in the same breath and it won't delay anything above. Until then: call your local emergency number now for anything in the red column.

Tonight, if she's her usual self and can keep sips down

That is the only situation in which home care is the right answer, and it's a good one to be in — so use the hour well.

• Dark, quiet, cool room, phone within reach, a bucket beside the bed. Migraine people want to lie still in the dark; let her have the position she picks, and if she is vomiting, keep her sitting up or lying on the side that makes it easier.
• Small amounts, often, of whatever stays down. The electrolyte drink is fine *if it is a rehydration sachet mixed as the packet says*; a sports drink is not the same thing and does not replace what hours of vomiting take out. I am not giving you a volume or a schedule — the aim is simply "it stays down", and the packet is the right source for how much.
• Only her own usual migraine plan, exactly as her prescriber instructed. No new tablet, no borrowed one, no leftover anti-sickness from a previous prescription, no opioids — and no "she's tougher than that" reasoning at 2am.
• The cold pack is fine if it helps her. It is comfort, not treatment, and I won't pretend otherwise.
• Write the times down while you have them: when the pain started, whether it built over hours or hit at full force in seconds, what she took and when, what she managed to keep down, and when she last passed urine. This is the single thing that makes an emergency department or a clinic move fast, and it takes two minutes.

1. What you already did vs. what I'd change

You used the worst possible trip-wire: "she can't keep water down." By the time that is true, the decision has been made for you and you are driving at night. The better trip-wire is a list agreed *in advance, on a good day*, containing only things visible early — the ones in the red column below.

Two things to add to that conversation, and neither is a medicine decision:

1. "Is this the same migraine she always gets?" A clear change in a known pattern is treated as a new problem until a clinician says otherwise — not as a bad attack. Recurrent, stereotyped attacks in a well person are usually the familiar primary kind; that labelling is her clinician's to make, not yours at 1am.
2. "Does the vomiting change the plan?" Hours of vomiting is the part that turns a migraine into a hospital visit on its own, and most home plans never address it. When she's well, ask her prescriber for a written plan that says what to do when the vomiting starts, and what should send her in. Get it on paper for the fridge.

And book a routine appointment even when an attack settles. Not urgent, but worth doing: a pattern with hours of vomiting deserves one proper review, and a diary is what lets the clinician see the pattern instead of hearing "she's always had migraines". Ask what her limit is for how often she uses acute pain relief — that number is the clinician's to set, not mine to guess, and it is the most useful thing in a diary conversation.

2. Don't do

• Don't wait twelve hours again. The rule is: her usual attack, well person, fluids staying down.
• Don't borrow or buy a migraine or anti-sickness tablet, and don't start a new one from this conversation. Only what her own prescriber advised, used as advised.
• Don't give opioids, and don't take someone else's prescription.
• Don't treat "the vomiting stopped after her anti-sickness tablet" as proof the dangerous causes are excluded. That is a false all-clear, and it is a common one.
• Don't wait for a stiff neck before taking a sudden worst-ever headache seriously, and don't wait for a first-ever weakness to pass.
• Don't assume a fading aura settles the question. A first-ever aura is not a reassuring sign, it is an unexplained one.
• Don't let her drive herself if she's drowsy, unsteady, or mid-attack, and don't let "she'll sleep it off" substitute for assessment after a head knock or a new neurological sign.
• Don't use a normal-feeling morning, a normal blood pressure, or a normal temperature as proof this is only a migraine.

3. Red flags — when to stop home care

🔴 Call your local emergency number now

• A headache that hit at full force within seconds, the worst she has ever had. A person who already gets migraines can still have this one. Her neck not being stiff is not reassurance, and you do not wait for it to become stiff.
• New one-sided weakness or numbness, slurred or lost speech, sudden vision loss or double vision, sudden dizziness with loss of balance — or a first-ever aura unlike her usual. Note the time she was last seen well; that is the number the team needs first.
• A fit, or confusion, drowsiness, or being hard to rouse.
• Fever with a bad headache, a stiff neck, or becoming lethargic.
• Flashing or flickering vision, or a red painful eye with rainbow rings around lights.
• A severe headache with visual change during pregnancy or in the weeks after birth — or vomiting that will not stop with pregnancy possible: that is go-now, and the same applies if she is passing almost no urine or dizzy on her feet. Say it early; it changes the whole pathway.
• Vomiting blood or coffee-ground material, a hard or swollen belly, or severe belly pain.
• She cannot keep fluids down, is passing almost no urine, or is struggling to stand without help.
• A head knock followed by headache, and she is getting sleepier rather than better.

🟨 Same day, not tonight's watch-and-wait

• This attack is clearly different from her usual one, or the pattern has changed over recent weeks.
• New or more frequent attacks, or headaches on most mornings.
• Her usual pain relief isn't lasting, or she has needed it more often lately.
• Vomiting continues well past what is normal for her, or she needs help to walk.
• She recovers from the attack but the diary shows a run of them.

🟩 Home is reasonable only if

It is her usual migraine, she is alert and walking normally, no red flag above, and sips are staying down. Then it is: dark quiet room, small amounts of fluid, her own prescribed plan, and a written record of the times.

Thursday, and the 15:00 pickup

• Agree the trip-wire on a good day, not during an attack. One paragraph on the fridge: *if any of these, we go, and the 15:00 pickup is covered by ____.* Write the backup's name in now.
• If she does have to go and it lands on the pickup, the school line is one sentence: "My wife is unwell and may be at a medical appointment at 15:00; ____ is collecting today and I have told them what to pass on." No medical detail is owed to the school.
• If it happens at work, the message to her employer is equally short: "I may need to collect the children at 15:00 today; I'll confirm by noon either way."
• If she goes to an emergency department, take the diary, her medicine list, and a note of the exact time it started. Ten seconds of that can change what happens next, and it protects her if she is asked questions while trying to remember through pain.

What "success" looks like in the next 24 hours

1. ✅ The trip-wire is written down, agreed while she is well, and has a named person on the 15:00 pickup line.
2. ✅ The three-line tree is on the fridge, in her language too if she wants it.
3. ✅ Dark room, bucket, phone, and rehydration sachet ready before the next attack.
4. ✅ Times written down during the attack: start, build or sudden, what she took, what stayed down, last urine.
5. ✅ No new, borrowed, or leftover medicine, and nothing changed in her prescribed plan.
6. ✅ A routine appointment booked or requested, with the diary in front of the clinician.
7. ✅ A written plan from her prescriber for the vomiting specifically — that's the piece that was missing.
8. ✅ Everyone in the house knows that "she can't keep water down" means go, not wait.

I can't promise the attack ends tonight, or that the next one is milder — anyone who told you otherwise would be guessing. What I can tell you is that the two things that made last time expensive were both avoidable: no trip-wire agreed in advance, and no written plan for the vomiting. Both are free, both are available on a good day, and one of them is a ten-minute conversation with her prescriber.

The whole thing is on a one-pager for the fridge and the appointment:

migraine-vomiting-visit-note-4caa7945.pdf

*Based on the family-triage guidance for adult headache and for vomiting: the red flags that mean emergency care, the level that means a clinician today, and the home-side care that is reasonable only in a well person with a known, typical attack. I cannot diagnose, calculate a dose, or change a medicine — those are the clinician's calls, and nothing here is a substitute for being seen.*