From the Guidelines
A headache cocktail typically consists of a combination of medications, including an NSAID such as ketorolac (30mg), an antihistamine like diphenhydramine (25-50mg), and an antiemetic like metoclopramide (10mg) or prochlorperazine (10mg), which work synergistically to reduce pain, inflammation, and nausea. The choice of medications may vary depending on the severity of the headache, the presence of nausea or vomiting, and the patient's medical history. According to the study by 1, NSAIDs such as ibuprofen (400-800mg) or naproxen sodium (275-550mg) can be used for mild to moderate migraine attacks, while more severe attacks may require the use of migraine-specific agents like triptans or DHE.
The use of adjunctive therapy, such as metoclopramide or prochlorperazine, can help treat associated symptoms like nausea and vomiting, and improve gastric motility. The study by 1 also notes that caffeine can be used to enhance pain relief by constricting blood vessels and increasing the absorption of pain medications. However, it is essential to use these combinations under medical supervision due to potential side effects and drug interactions.
Some key points to consider when prescribing a headache cocktail include:
- Using a non-oral route of administration for patients with nausea or vomiting
- Selecting medications that are effective for the patient's specific type of headache
- Monitoring for potential side effects and drug interactions
- Educating patients on the proper use of the medications and the importance of follow-up care. As noted in the study by 1, the most consistent evidence exists for the use of NSAIDs like aspirin, ibuprofen, and naproxen sodium, as well as combination agents like acetaminophen plus aspirin plus caffeine, for the treatment of acute migraine attacks.
From the Research
Composition of a Headache Cocktail
The composition of a headache cocktail typically consists of a combination of medications, including:
- Acetaminophen (Tylenol) or aspirin as a pain reliever 2, 3, 4, 5
- An antiemetic, such as metoclopramide, to reduce nausea and vomiting 6, 4, 5
- A corticosteroid, such as dexamethasone, to prevent short-term headache recurrence 5
Medications Used in Headache Cocktails
Some studies suggest the following medications can be used in headache cocktails:
- Nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen or naproxen, for mild to moderate migraines 2, 3, 5
- Triptans, such as sumatriptan, for moderate to severe migraines 2, 3, 4, 5
- Combination analgesics containing acetaminophen, aspirin, and caffeine for mild to moderate migraines 5
- Intravenous antiemetics, with or without intravenous dihydroergotamine, for emergency department settings 5
Efficacy and Tolerability
The efficacy and tolerability of these medications have been studied, with results showing:
- Paracetamol (acetaminophen) 1000 mg alone is statistically superior to placebo in the treatment of acute migraine, but with a lower NNT compared to other commonly used analgesics 4
- The addition of 10 mg metoclopramide to paracetamol gives short-term efficacy equivalent to oral sumatriptan 100 mg 4
- Adverse event rates are similar between paracetamol and placebo, and between paracetamol plus metoclopramide and sumatriptan 4