What medications are used in a migraine cocktail for acute migraine treatment?

Medications for Migraine Cocktail in Acute Treatment

A migraine cocktail typically includes a combination of NSAIDs, triptans, antiemetics, and sometimes other adjunctive medications to effectively treat acute migraine attacks and associated symptoms. 1

First-Line Medications (Mild to Moderate Migraines)

NSAIDs

• Aspirin: 650-1000 mg every 4-6 hours (maximum 4g daily)
• Ibuprofen: 400-800 mg every 6 hours
• Naproxen sodium: 500-550 mg at onset, followed by 250-275 mg every 6-8 hours
• Diclofenac potassium: 50-100 mg at onset

NSAIDs are most effective when taken early in the attack while pain is still mild 1. Acetaminophen alone is not recommended for migraine treatment but can be effective in combination with aspirin and caffeine 1.

Second-Line Medications (Moderate to Severe Migraines)

Triptans

• Sumatriptan:
  • Oral: 50-100 mg (preferred over 25 mg due to better efficacy) 2, 3
  • Subcutaneous: 6 mg (fastest onset, useful for rapid-onset migraines)
  • Intranasal: 5-20 mg
• Rizatriptan: 5-10 mg oral (available as regular tablet or orally disintegrating)
• Zolmitriptan: 2.5-5 mg oral
• Naratriptan: 1-2.5 mg oral (longer half-life, may reduce recurrence)

Triptans should be taken early in the headache phase but not during aura 1. If one triptan fails, another may still be effective 1.

Combination Therapy

• Sumatriptan + naproxen: Combining these medications provides better relief than either medication alone 4
• Aspirin + acetaminophen + caffeine: Effective combination for mild to moderate attacks 1
• Isometheptene + acetaminophen + dichloralphenazone (Midrin): Effective for milder migraine headaches 1

Antiemetics/Adjunctive Medications

• Metoclopramide: 10 mg IV or oral - treats nausea and improves gastric motility 1
• Prochlorperazine: 10 mg IV or oral - effectively relieves headache pain and nausea 1
• Domperidone: Oral antiemetic for nausea/vomiting 1

Algorithm for Migraine Cocktail Selection

1. For mild to moderate attacks without significant nausea/vomiting:

   • Start with NSAID (ibuprofen 800 mg or naproxen 500 mg)
   • Add caffeine if available

2. For moderate to severe attacks or those with significant nausea/vomiting:

   • Triptan (sumatriptan 50-100 mg preferred)
   • Add antiemetic (metoclopramide 10 mg or prochlorperazine 10 mg)
   • Consider non-oral routes if vomiting is present

3. For attacks not responding to single agents:

   • Combination of triptan + NSAID (sumatriptan + naproxen)
   • Add antiemetic if nausea/vomiting is present

4. For refractory attacks:

   • Dihydroergotamine (DHE) nasal spray or injection
   • Consider rescue medication (avoiding opioids if possible)

Important Considerations and Caveats

• Route of administration: Use non-oral routes (intranasal, subcutaneous, suppository) when significant nausea/vomiting is present 1
• Medication overuse: Limit acute medications to no more than 2 days per week to prevent medication overuse headache 1
• Avoid: Oral ergot alkaloids, opioids, and barbiturates due to questionable efficacy, adverse effects, and risk of dependency 1
• Timing: Medications are most effective when taken early in an attack while pain is still mild 1
• Recurrence: If headache recurs within 24 hours, a second dose of triptan may be taken, but be cautious about medication overuse 1

For patients with frequent migraines (≥2 attacks/month causing disability), preventive therapy should be considered alongside acute treatment strategies 1.