What is the composition of the headache cocktail in urgent care, typically including Toradol (ketorolac) and prednisone, and are there any additional medications?

Headache Cocktail in Urgent Care Setting

The most effective headache cocktail in urgent care settings consists of ketorolac (Toradol) 30-60mg IM/IV, metoclopramide 10mg IV, and prochlorperazine 10mg IV, rather than prednisone which has limited evidence for acute headache treatment. 1, 2

First-Line Components of the Headache Cocktail

• Ketorolac (Toradol): The primary NSAID component, typically administered at 30mg IV or 60mg IM for patients under 65 years of age (reduced to 15mg IV or 30mg IM for patients ≥65 years or with renal impairment) 1, 3
• Metoclopramide (10mg IV): Provides both antiemetic effects and synergistic analgesia for migraine pain 2
• Prochlorperazine (10mg IV): Effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy 1, 2

Additional Components Sometimes Added

• Diphenhydramine (25-50mg IV): Often added to prevent akathisia and extrapyramidal side effects from metoclopramide or prochlorperazine 2
• Caffeine: Can serve as an adjunctive therapy providing synergistic analgesia when combined with other medications 2
• Magnesium sulfate: May be beneficial particularly for migraine with aura 4

Role of Corticosteroids (Prednisone/Dexamethasone)

• Contrary to common practice, corticosteroids like prednisone have limited evidence supporting their use in acute migraine treatment 1, 5
• Corticosteroids are more appropriate for status migrainosus (severe, continuous migraine lasting up to one week) rather than routine acute headache treatment 1, 5
• When used, short courses of rapidly tapering doses of oral corticosteroids (prednisone or dexamethasone) can help alleviate status migraine 5

Administration Guidelines

• IV medications should be administered slowly (ketorolac IV bolus must be given over no less than 15 seconds) 3
• IM injections should be given slowly and deeply into the muscle 3
• The analgesic effect of ketorolac begins in approximately 30 minutes with maximum effect in 1-2 hours and duration of 4-6 hours 3

Important Considerations and Cautions

• Medication-overuse headache can result from frequent use of acute medications (more than twice weekly) 1, 2
• Ketorolac should not be used for more than 5 days due to increased risk of GI bleeding and renal effects 3
• Ketorolac should be used with caution in patients with renal impairment, history of GI bleeding, or heart disease 2, 3
• Avoid opioids for migraine treatment as they can lead to dependency, rebound headaches, and eventual loss of efficacy 2, 6
• Ketorolac should not be mixed in a small volume with morphine, meperidine, promethazine, or hydroxyzine as this will result in precipitation 3

Treatment Algorithm for Urgent Care Headache Management

1. First-line: Ketorolac 30mg IV (or 60mg IM) + metoclopramide 10mg IV or prochlorperazine 10mg IV 1, 2
2. Consider adding diphenhydramine 25-50mg IV if using metoclopramide or prochlorperazine to prevent akathisia 2
3. For persistent severe headache or status migrainosus, consider adding a short course of corticosteroids 1, 5
4. For patients with contraindications to NSAIDs, consider dihydroergotamine (DHE) as an alternative 1, 6
5. Begin treatment as early as possible during the attack to improve efficacy 2

By following this evidence-based approach to headache management in urgent care, clinicians can provide effective relief while minimizing the risk of adverse effects and medication overuse.