What is a common migraine cocktail given in primary care for a migraine?

Common Migraine Cocktail in Primary Care

The most common and effective migraine cocktail in primary care consists of an NSAID (such as ibuprofen 400-800mg or naproxen 500-550mg) combined with a triptan (such as sumatriptan 50-100mg) for moderate to severe migraines. 1, 2

First-Line Treatment Options

For Mild to Moderate Migraines:

• NSAIDs:
  • Ibuprofen 400-800mg
  • Naproxen sodium 500-550mg
  • Diclofenac potassium
  • Acetylsalicylic acid (Aspirin) 1000mg 1, 3
• Acetaminophen: 1000mg (alternative if NSAIDs contraindicated) 2

For Moderate to Severe Migraines:

• Triptans:
  • Sumatriptan 50-100mg (most commonly used)
  • Rizatriptan
  • Eletriptan 2, 4

Combination Therapy:

• Triptan + NSAID (provides better relief than either medication alone) 2
• Triptan + acetaminophen 2

Additional Medications Often Added to the Cocktail

Antiemetics:

• Metoclopramide 10mg (higher doses don't provide additional benefit) 5
• Domperidone 20mg 6

Important Dosing Considerations:

• Sumatriptan: Start with 50mg; may increase to 100mg if needed (100mg may not provide greater effect than 50mg) 4
• Maximum daily dose of sumatriptan: 200mg in a 24-hour period 4
• If migraine hasn't resolved after 2 hours, a second dose may be administered 4
• Patients with hepatic impairment: maximum single dose of sumatriptan should not exceed 50mg 4

Treatment Algorithm

1. Assess migraine severity:

   • Mild to moderate: Start with NSAID
   • Moderate to severe: Use triptan or triptan + NSAID/acetaminophen

2. If nausea/vomiting present: Add antiemetic (metoclopramide 10mg)

3. If inadequate response after 2 hours: Consider second dose of triptan (ensuring at least 2-hour interval between doses)

4. For recurrent migraines: Consider preventive therapy if experiencing ≥4 headaches per month or ≥8 headache days per month 2

Important Cautions

• Limit NSAID use to 2-3 days/week to prevent medication overuse headache 2
• Avoid opioids and butalbital-containing medications due to risk of medication overuse headache and dependence 2
• The safety of treating more than 4 headaches in a 30-day period with triptans has not been established 4
• Triptans are contraindicated in patients with cardiovascular disease 2

Second-Line Options

If first-line treatments fail, consider:

• CGRP antagonists (gepants) such as rimegepant or ubrogepant 2
• Dihydroergotamine (DHE) 3
• Referral to specialist for refractory migraines 2

By following this stepwise approach to migraine management in primary care, you can effectively address acute migraine attacks while minimizing adverse effects and preventing medication overuse headache.