What is the composition of the migraine cocktail in a hospital setting?

The Migraine Cocktail in Hospital Setting

The standard migraine cocktail in a hospital setting typically consists of a combination of a triptan (such as sumatriptan) and an NSAID (such as naproxen), which is strongly recommended as the most effective treatment for moderate to severe acute migraine headaches. 1

Components of the Migraine Cocktail

The migraine cocktail typically includes:

First-Line Components

• Triptan + NSAID combination:
  • Sumatriptan (typically 6 mg subcutaneous or 100 mg oral) with naproxen (500-550 mg)
  • This combination has shown the greatest net benefit with high-certainty evidence for sustained pain relief up to 48 hours 1

Additional/Alternative Components

• Triptan + acetaminophen combination:

  • Rizatriptan with acetaminophen (1000 mg)
  • Recommended when NSAIDs are contraindicated or not tolerated 1

• Antiemetic medications (for associated nausea/vomiting):

  • Metoclopramide (10 mg IV)
  • Prochlorperazine (10 mg IV) 2

Treatment Algorithm

1. Initial Assessment:

   • Determine migraine severity (moderate to severe)
   • Check for contraindications to triptans (cardiovascular disease, uncontrolled hypertension)
   • Assess for nausea/vomiting

2. First-Line Treatment:

   • Triptan + NSAID combination 1
     • Provides 130 more events of sustained pain relief per 1000 treated people
     • Reduces rescue medication use by 130 fewer events per 1000 treated people

3. If First-Line Contraindicated:

   • Triptan + acetaminophen combination 1
     • Provides 300 more events of pain freedom at 2 hours per 1000 treated people
     • Provides 250 more events of sustained pain freedom up to 48 hours per 1000 treated people

4. For Severe Nausea/Vomiting:

   • Add antiemetic (metoclopramide or prochlorperazine) 2
   • Consider non-oral route for triptan (subcutaneous, nasal)

Evidence Quality and Considerations

• The combination of triptan + NSAID has high-certainty evidence showing superior efficacy compared to monotherapy 1
• The combination of triptan + acetaminophen has moderate-certainty evidence for pain freedom at 2 hours 1
• Patient values research shows that people prioritize effectiveness for pain outcomes over side effects or route of administration 1

Important Cautions

• Avoid opioids for migraine treatment as they can lead to medication overuse headache and have significant side effects 1, 3
• Monitor for adverse effects of triptans (fatigue, dizziness, nausea) which are generally mild but can affect quality of life 1
• Timing matters - treatment should begin as early as possible after migraine onset for maximum efficacy 1
• Medication overuse headache risk increases with frequent use (≥10 days/month for triptans; ≥15 days/month for NSAIDs) 1

Special Populations

• Pregnancy: Acetaminophen is the safest option; triptans should be avoided 3
• Cardiovascular disease: Avoid triptans; consider NSAID + antiemetic combination 3
• Refractory migraine: Consider adding corticosteroids (dexamethasone 10 mg IV) to reduce headache recurrence after discharge 2

The migraine cocktail approach reflects the understanding that combination therapy targeting multiple pain pathways is more effective than monotherapy for moderate to severe migraine attacks, with the triptan + NSAID combination showing the strongest evidence for efficacy in reducing pain and preventing recurrence.