What is the typical regimen for a migraine cocktail treatment?

Migraine Cocktail Treatment Regimen

The standard migraine cocktail treatment consists of an NSAID (such as ibuprofen, aspirin, or naproxen sodium) as first-line medication, combined with a triptan as second-line therapy, and an antiemetic medication to address nausea and improve medication absorption. 1, 2

First-Line Medications

• NSAIDs are recommended as first-line therapy for mild to moderate migraine attacks due to their demonstrated efficacy and favorable tolerability 2, 1
• Effective NSAIDs with consistent evidence include:
  • Aspirin (900-1000mg as needed) 1, 2
  • Ibuprofen (400-800mg every 6-8 hours as needed) 1, 2
  • Naproxen sodium 2, 3
  • Diclofenac potassium 3

Second-Line Medications

• Triptans are recommended as second-line therapy for moderate to severe attacks or when NSAIDs fail 2, 1
• Effective triptans include:
  • Sumatriptan (25-100mg orally, 6mg subcutaneously, or intranasal) 2, 4
  • Rizatriptan 2
  • Zolmitriptan 2
  • Naratriptan 2
• Triptans should be taken early in the headache phase for maximum effectiveness 5
• Triptans are contraindicated in patients with cardiovascular disease, basilar or hemiplegic migraine, or uncontrolled hypertension 2

Antiemetic Adjuncts

• Antiemetics are valuable components of the migraine cocktail, particularly when nausea and vomiting are prominent 1, 6
• Recommended antiemetics include:
  • Metoclopramide - treats nausea and improves gastric motility 1, 6
  • Prochlorperazine - can relieve both headache pain and nausea 1
  • Domperidone 2

Alternative Medications

• Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy, particularly in intranasal form (0.5-1mg IM/IV or intranasal) 2, 1
• Combination analgesics containing acetaminophen, aspirin, and caffeine can be effective 3
• Gepants and ditans may be considered as third-line medications when triptans and NSAIDs fail 2

Administration Considerations

• For patients with significant nausea or vomiting, non-oral routes of administration should be considered 1, 2:
  • Subcutaneous sumatriptan (6mg) 4, 7
  • Intranasal triptans 2
  • Rectal or injectable NSAIDs when available 3
• Medication should be taken early in the attack for optimal efficacy 5
• If headache returns or response is partial, doses may be repeated after 2 hours (not exceeding maximum daily dose) 4

Important Cautions

• Acute therapy should be limited to no more than twice weekly to prevent medication-overuse headache 2, 3
• Opioids and barbiturates should be avoided due to questionable efficacy, adverse effects, and risk of dependency 2, 3
• Oral ergot alkaloids are poorly effective and potentially toxic, and should not be used as substitutes for triptans 2

Practical Algorithm for Migraine Cocktail Administration

1. For mild to moderate attacks:

   • Start with an NSAID (ibuprofen 800mg or naproxen sodium) 1, 2
   • Add an antiemetic if nausea is present (metoclopramide 10mg) 1, 6

2. For moderate to severe attacks:

   • Use a triptan (sumatriptan 50-100mg orally or 6mg subcutaneously) 2, 4
   • Consider combining with an NSAID for enhanced efficacy 3
   • Add an antiemetic (metoclopramide or prochlorperazine) 1

3. For refractory attacks:

   • Consider DHE (0.5-1mg IM/IV or intranasal) 2, 1
   • Combination of triptan plus NSAID plus antiemetic 3, 6
   • Rescue medications such as dopamine antagonists or corticosteroids when usual medications fail 8