From the Guidelines
The recommended migraine cocktail in the Emergency Department should include a combination of intravenous metoclopramide (10 mg) or prochlorperazine (10 mg), diphenhydramine (25-50 mg), and ketorolac (30 mg IV or 60 mg IM), with the option to add fluids, magnesium sulfate, dexamethasone, or sumatriptan as needed, based on the most recent and highest quality study available 1.
Migraine Cocktail Components
- Intravenous metoclopramide (10 mg) or prochlorperazine (10 mg) as the primary agent to address nausea and pain
- Diphenhydramine (25-50 mg) to prevent akathisia
- Ketorolac (30 mg IV or 60 mg IM) as an anti-inflammatory component to reduce inflammation and provide additional pain relief
Additional Options
- Fluids (typically 1 liter of normal saline) to address dehydration
- Magnesium sulfate (1-2 g IV) for severe, refractory migraines
- Dexamethasone (10 mg IV) to prevent recurrence
- Sumatriptan if not contraindicated
Considerations
- The choice of a specific NSAID or triptan should be based on individualized decision making, taking into consideration patient preferences and factors such as route of administration and cost 1
- The use of opioids or butalbital for the treatment of acute episodic migraine is not recommended 1
- Nonoral triptans and antiemetics should be considered for patients with severe nausea or vomiting 1
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Migraine Cocktail in the Emergency Department
The recommended migraine cocktail to order in the Emergency Department (ED) may include:
- Metoclopramide, prochlorperazine, and sumatriptan, which have multiple class 1 studies supporting acute efficacy 2
- Dexamethasone, which can be used to prevent recurrence of headache 2
- A combination of sumatriptan and metoclopramide, which has been shown to provide relief in some migraineurs who failed to achieve adequate relief with a triptan alone 3
Medications to Avoid
- Injectable morphine and hydromorphone, which are best avoided as first-line therapy due to lack of evidence demonstrating efficacy and concern about sub-acute or long-term sequelae 2
Treatment Approaches
- Intravenous metoclopramide and prochlorperazine, and subcutaneous sumatriptan should be offered to eligible adults who present to an ED with acute migraine 2
- Emerging evidence for nerve blocks and new pharmacological classes of medications like gepants and ditans may also be considered in the treatment of migraine in the ED 4