What comprises a migraine cocktail?

Migraine Cocktail Components

A migraine cocktail typically consists of a combination of medications including an NSAID (such as ketorolac or ibuprofen), an antiemetic (such as metoclopramide), and sometimes a dopamine antagonist, with additional components like diphenhydramine, magnesium, or corticosteroids depending on severity and symptoms. 1

Core Components of a Migraine Cocktail

First-Line Medications

• NSAIDs:

  • Ketorolac (Toradol) - typically 30mg IV or 60mg IM
  • Ibuprofen - 400-800mg oral
  • Naproxen sodium - 275-550mg oral
  • Aspirin - 650-1000mg oral 1

• Antiemetics/Dopamine Antagonists:

  • Metoclopramide (Reglan) - 10mg IV, which serves both as an antiemetic and has independent analgesic properties 2, 1
  • Prochlorperazine (Compazine) - 10mg IV or IM

• Diphenhydramine (Benadryl) - 25-50mg IV, often added to prevent extrapyramidal side effects from metoclopramide or prochlorperazine

Additional Components Based on Severity

• Magnesium sulfate - 1-2g IV, particularly useful for patients with aura or menstrual-related migraines
• Dexamethasone - 10mg IV, often added to prevent headache recurrence
• Fluids - IV normal saline, especially for dehydrated patients

Second-Line Medications

• Triptans (if not already tried by patient):

  • Sumatriptan - 6mg subcutaneously for severe attacks with significant nausea/vomiting, or 50-100mg orally
  • Rizatriptan - 10mg orally 1

• Dihydroergotamine (DHE) - 0.5-1mg IV or IM, particularly effective for status migrainosus 2

Administration Considerations

• Medications in a migraine cocktail are typically administered sequentially rather than mixed together
• IV administration is preferred in emergency settings for faster relief
• Oral combinations may be used in outpatient settings for milder cases

Tailoring the Cocktail

The specific components of a migraine cocktail should be selected based on:

1. Severity of pain - More components for severe pain
2. Presence of nausea/vomiting - Prioritize antiemetics and non-oral routes
3. Duration of attack - Consider adding dexamethasone for prolonged attacks
4. Previous medication response - Avoid medications that failed previously
5. Contraindications - Avoid triptans in patients with cardiovascular conditions 1

Important Cautions

• Avoid opioids when possible due to risk of dependence and medication overuse headache 1
• Limit triptan use to fewer than 9 days per month to prevent medication overuse headache 1
• Monitor for side effects of dopamine antagonists, particularly akathisia and dystonic reactions
• Be cautious with NSAIDs in patients with renal impairment, history of GI bleeding, or heart disease

The emergency department migraine cocktail approach is particularly useful for patients with severe, refractory migraines who have failed outpatient treatments or who present with status migrainosus (migraine lasting >72 hours).