Migraine Cocktail Components
A migraine cocktail typically consists of a combination of medications including NSAIDs, antiemetics, and sometimes triptans or dihydroergotamine, administered together to treat acute migraine attacks, particularly those that are severe or refractory to single-agent therapy. 1, 2
Core Components of a Migraine Cocktail
Primary Pain Medications
- NSAIDs: First-line agents for mild to moderate migraine attacks, with good evidence for efficacy of aspirin, ibuprofen, naproxen sodium, and diclofenac potassium 1, 2
- Triptans: First-line for moderate to severe attacks, including sumatriptan, rizatriptan, eletriptan, zolmitriptan, almotriptan, frovatriptan, and naratriptan 1, 2
- Dihydroergotamine (DHE): Considered appropriate for treatment of severe migraines, available in parenteral preparations and as a nasal spray 1
Antiemetics/Adjunctive Therapy
- Metoclopramide: Typically administered at 10 mg IV or orally 20-30 minutes before or with other medications to treat nausea and enhance absorption 1
- Prochlorperazine: Highly effective (rated 4/4 for efficacy) at 25 mg orally or as a suppository, with a maximum of three doses per 24 hours 1
Other Components
- Isometheptene combinations (with acetaminophen and dichloralphenazone): Rated 3/4 for efficacy, with an initial dose of two capsules followed by one capsule per hour up to five capsules per 12 hours 1
- Butorphanol: Nasal spray with good evidence for efficacy, though opioids are generally reserved for when other medications cannot be used 1
Administration Strategies
Emergency Department/Infusion Center Setting
- Standard Cocktail: Often includes an IV NSAID (ketorolac), an antiemetic (prochlorperazine or metoclopramide), and sometimes IV fluids for hydration 1
- Refractory Attacks: May add IV dihydroergotamine, which has good evidence for efficacy and safety 1, 2
Outpatient Setting
- Combination Therapy: Evidence supports combining a triptan with an NSAID for improved efficacy and reduced recurrence compared to either medication alone 3, 4
- Oral Cocktail: May include an oral NSAID, an oral triptan, and an antiemetic as needed 2, 5
Important Considerations and Contraindications
- Cardiovascular Risk: Triptans and ergot derivatives are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, or other significant cardiovascular disease 6, 7
- Medication Overuse: Acute therapy should be limited to no more than twice weekly to prevent medication-overuse headache 1, 2
- Sedation: Many components of migraine cocktails, particularly antiemetics and opioids, can cause significant sedation 1, 8
- Extrapyramidal Symptoms: Prochlorperazine and metoclopramide can cause akathisia, dystonia, and other movement disorders 8
Evidence-Based Approach to Selection
- For mild to moderate attacks: Start with NSAIDs (ibuprofen 400-800mg or naproxen sodium) 2, 9
- For moderate to severe attacks: Use a triptan (sumatriptan 50-100mg orally or 6mg subcutaneously) 2, 4
- For attacks with significant nausea: Add an antiemetic (prochlorperazine or metoclopramide) 1
- For refractory attacks: Consider combination therapy with a triptan plus NSAID, or DHE 3, 5
By understanding the components and appropriate use of migraine cocktails, clinicians can provide effective relief for patients suffering from acute migraine attacks while minimizing adverse effects and preventing medication overuse.