What constitutes a good migraine cocktail?

Optimal Migraine Cocktail for Acute Treatment

The most effective migraine cocktail for moderate to severe migraine attacks is a combination of a triptan (such as sumatriptan) with a nonsteroidal anti-inflammatory drug (NSAID) or acetaminophen, along with an antiemetic if nausea or vomiting is present. 1

First-Line Treatment Options

For Mild Migraine Attacks:

• NSAIDs alone (options include):
  • Ibuprofen 400-800mg
  • Naproxen sodium 500-550mg
  • Aspirin 900-1000mg
  • Diclofenac potassium 50mg
• Acetaminophen 1000mg
• Aspirin-acetaminophen-caffeine combination (strongly recommended) 1

For Moderate to Severe Migraine Attacks:

1. Start with an NSAID or acetaminophen
2. Add a triptan if inadequate response 1

Triptan Options:

• Sumatriptan 25mg, 50mg, or 100mg (oral)
  • 50mg and 100mg doses provide greater effect than 25mg
  • Maximum daily dose: 200mg in a 24-hour period
  • Second dose may be taken if migraine persists after 2 hours 2
• Other triptans: almotriptan, eletriptan, frovatriptan, naratriptan, rizatriptan, zolmitriptan 1

Route Considerations:

• For patients with significant nausea/vomiting: Consider non-oral triptan formulations (nasal, injectable) plus an antiemetic 1

Timing and Administration

• Begin treatment as early as possible after migraine onset
• Early intervention with combination therapy improves efficacy 1
• If using sumatriptan, a second dose may be administered if migraine hasn't resolved after 2 hours (maintain minimum 2-hour interval between doses) 2

For Treatment-Resistant Migraines

If initial treatment is inadequate, consider:

• CGRP antagonist-gepant (rimegepant, ubrogepant, or zavegepant)
• Dihydroergotamine
• Lasmiditan (ditan) 1

Important Contraindications and Precautions

Triptan Contraindications:

• Cerebrovascular disease
• Coronary artery disease
• Uncontrolled hypertension
• Hemiplegic migraine
• Recent (within 24 hours) use of another triptan or ergotamine-containing medication
• Concurrent or recent (past 2 weeks) use of MAO-A inhibitor
• Wolff-Parkinson-White syndrome or other cardiac conduction disorders 1, 2

NSAID Precautions:

• Use with caution in patients with gastrointestinal, renal, or cardiovascular disease 1

Monitoring and Avoiding Medication Overuse

• Be vigilant for medication overuse headache (occurs ≥15 days/month for ≥3 months)
• Risk thresholds: ≥15 days/month with NSAIDs and ≥10 days/month with triptans 1
• Patients using acute medications more than 10-15 days/month may perpetuate headaches 1

Common Side Effects to Monitor

• Triptan side effects: paresthesia, warm/cold sensation, chest pain/tightness/pressure, neck/throat/jaw pain/tightness/pressure, dizziness, malaise/fatigue 2
• NSAID side effects: gastrointestinal upset, risk of bleeding

Clinical Pearl

Diclofenac potassium 50mg has been shown to have a faster onset of action than oral sumatriptan in some studies, with better reduction of accompanying symptoms, particularly nausea 3. This may make it an excellent choice for patients who need rapid relief or have prominent nausea with their migraines.

Medications to Avoid

• Opioids and butalbital should not be used for acute migraine treatment 1

Remember that treating early in the mild pain phase gives significantly better outcomes than treating established attacks with moderate or severe pain intensity 4. A headache diary can help track headache frequency, intensity, duration, medication use, potential triggers, and response to treatments.