From the Guidelines
A migraine cocktail typically consists of a combination of medications designed to relieve severe migraine symptoms, including an NSAID, an antiemetic, and a diphenhydramine component. The most common formulation includes an NSAID (like ketorolac 30mg IV or ibuprofen 600-800mg orally), an antiemetic (such as metoclopramide 10mg IV/oral or prochlorperazine 10mg IV/oral), and a diphenhydramine component (25-50mg IV/oral) to reduce side effects 1. Some cocktails may also include IV fluids for hydration, especially for patients experiencing vomiting or dehydration. In emergency settings, more potent combinations might incorporate dexamethasone (10mg IV) to prevent headache recurrence, or magnesium sulfate (1-2g IV) which can help relax blood vessels.
These medications work together synergistically - NSAIDs reduce inflammation and pain, antiemetics address nausea while also having independent pain-relieving properties, and diphenhydramine prevents medication side effects like akathisia. The specific components may be adjusted based on the patient's symptoms, medical history, and previous medication responses. Patients should be aware that drowsiness is a common side effect, so they should avoid driving after receiving this treatment. According to the study published in the Annals of Internal Medicine 1, the choice of treatment should be based on the frequency and severity of attacks, the presence and degree of temporary disability, and the profile of associated symptoms, such as nausea and vomiting.
Key considerations when administering a migraine cocktail include:
- Using a nonoral route of administration for patients whose migraines present early with nausea or vomiting as a significant component of the symptom complex 1
- Treating nausea and vomiting with an antiemetic, as nausea itself is one of the most aversive and disabling symptoms of a migraine attack 1
- Limiting acute therapy to no more than two times per week to guard against medication-overuse headache (or drug-induced headache) 1
- Considering preventive migraine therapy in patients with suspected medication overuse or patients at risk for medication overuse 1
From the Research
Migraine Cocktail Composition
The composition of a migraine cocktail can vary, but it often includes a combination of medications to relieve migraine symptoms. Based on the provided studies, some common components of a migraine cocktail are:
- Metoclopramide: a dopaminergic antagonist that can help relieve migraine pain and associated symptoms 2, 3, 4, 5, 6
- Sumatriptan: a 5-HT1B/1D agonist that can help relieve migraine pain 2, 3, 5, 6
- Other medications: such as granisetron, ketorolac, chlorpromazine, and Dexketoprofen trometamol, which can also be used to relieve migraine symptoms 4
Dosages and Administration
The dosages and administration routes of these medications can vary. For example:
- Metoclopramide: 10 mg IV or 20 mg IV, given up to four times over 2 hours as needed for persistent headache 4, 6
- Sumatriptan: 50 mg or 6 mg subcutaneously 2, 6
Efficacy and Safety
The efficacy and safety of these medications in relieving migraine symptoms have been studied. For example:
- Metoclopramide has been shown to be effective in reducing headache outcomes, even for 24 hours, and has a lower incidence of mild side effects compared to some other medications 4
- Sumatriptan has been shown to be effective in relieving migraine pain, but may have some contraindications and possible severe side effects 3