What is a migraine cocktail?

Migraine Cocktail: Combination Therapy for Acute Migraine Management

A migraine cocktail is a combination of medications used to treat acute migraine attacks, typically including an NSAID or analgesic, an antiemetic, and sometimes a migraine-specific medication such as a triptan or dihydroergotamine (DHE), administered together to provide rapid and effective relief of migraine symptoms. 1

Components of a Migraine Cocktail

First-Line Medications

• NSAIDs form the foundation of most migraine cocktails for mild to moderate attacks, with options including aspirin (650-1000mg), ibuprofen (400-800mg), or naproxen sodium (275-550mg) 2
• Combination analgesics containing acetaminophen-aspirin-caffeine are effective and commonly included (acetaminophen alone is ineffective) 1, 2
• Triptans (sumatriptan, rizatriptan, naratriptan, zolmitriptan) are included for moderate to severe migraines or when NSAIDs provide inadequate relief 1, 2
• Dihydroergotamine (DHE) may be included for severe migraines, available in parenteral preparations and nasal spray 1

Antiemetics/Adjunctive Therapy

• Metoclopramide (10mg IV or oral) is included to treat accompanying nausea and improve gastric motility during attacks 1, 2
• Prochlorperazine (25mg oral or suppository) can effectively relieve both headache pain and nausea 1
• Caffeine is often included as an adjunctive therapy to enhance analgesic effects 1

Administration Approaches

Route of Administration

• For migraines with significant nausea or vomiting, non-oral routes should be selected 1, 2
• Options include:
  • Subcutaneous injectable sumatriptan (reaches peak blood concentration in approximately 15 minutes) 1
  • Intranasal DHE or sumatriptan 1
  • Rectal suppositories (prochlorperazine, NSAIDs) 1
  • Intravenous administration (often used in emergency settings) 1

Timing Considerations

• Administration as early as possible during an attack improves efficacy 1
• Acute therapy should be limited to no more than twice per week to guard against medication-overuse headaches 1

Treatment Algorithm

For Mild to Moderate Migraines:

1. Start with NSAID (ibuprofen, naproxen sodium, or aspirin) plus metoclopramide for nausea 1, 2
2. If inadequate response, add caffeine-containing combination analgesic 1, 2
3. Consider isometheptene combinations if above options fail 1

For Moderate to Severe Migraines:

1. Use migraine-specific drugs (triptans or DHE) plus an antiemetic 1
2. Consider combination therapy with NSAID plus triptan for enhanced efficacy 1, 2
3. For severe, refractory migraines, consider rescue medications such as butorphanol nasal spray 1

Important Considerations and Cautions

• Contraindications: Triptans should not be used in patients with uncontrolled hypertension, coronary artery disease, or basilar/hemiplegic migraine 1, 2
• Medication Overuse: Limit use of acute migraine cocktails to prevent medication-overuse headaches, which can result from frequent use 1
• Rebound Headaches: Be aware that ergotamine, opiates, triptans, and analgesics containing butalbital, caffeine, or isometheptene can cause rebound headaches 1
• Preventive Therapy: Consider preventive therapy if migraines occur more than twice weekly or if acute treatments fail 1

Emergency Department Migraine Cocktails

In emergency settings, migraine cocktails often include:

• Intravenous metoclopramide or prochlorperazine as primary agents 1, 2
• Intravenous NSAIDs such as ketorolac 1
• Parenteral DHE for severe cases 1
• Avoidance of opioids when possible due to risk of dependency and rebound headaches 1

By using a migraine cocktail approach that combines medications targeting different aspects of migraine pathophysiology, patients can achieve more rapid and complete relief than with single-agent therapy alone 1, 2.