What is the typical migraine cocktail regimen used in the Emergency Department (ED) for treating migraines?

Standard Migraine Cocktail Regimen in the Emergency Department

The standard migraine cocktail in the emergency department typically consists of an NSAID (such as ketorolac), an antiemetic (such as metoclopramide or prochlorperazine), and a triptan (such as sumatriptan) for moderate to severe migraines. 1, 2

First-Line Medications

• NSAIDs are recommended as first-line treatment for mild to moderate migraine attacks in the ED 1, 3

  • Common options include ketorolac (30mg IV/IM), ibuprofen (400-800mg), naproxen sodium, or aspirin
  • These medications inhibit cyclooxygenase enzymes, reducing prostaglandin synthesis and inflammation 3

• Antiemetics serve dual purposes:

  • Treating nausea/vomiting associated with migraines
  • Improving gastric motility which may be impaired during attacks 1
  • Common options include metoclopramide (10mg IV) or prochlorperazine (10mg IV) 3

Second-Line Medications

• Triptans are first-line for moderate to severe attacks or when NSAIDs fail 3

  • Sumatriptan is most commonly used in the ED setting:
    • 6mg subcutaneous (fastest onset, most effective)
    • 25-100mg oral (slower onset)
    • 5-20mg intranasal (intermediate onset) 4, 5
  • Subcutaneous sumatriptan provides complete pain relief in approximately 59% of patients within 2 hours compared to 15% with placebo 5

• Dihydroergotamine (DHE) 0.5-1mg IV/IM/intranasal is effective for refractory cases 6, 1

  • Good evidence supports intranasal DHE efficacy and safety 6

Route of Administration Considerations

• For patients with significant nausea or vomiting, non-oral routes are preferred 1, 7

  • Subcutaneous (fastest onset)
  • Intranasal (intermediate onset)
  • Rectal (alternative when IV access unavailable) 7, 5

• IV hydration is often included in the cocktail, especially for patients with prolonged symptoms or signs of dehydration 2

Refractory Migraine Options

• IV magnesium sulfate (1-2g) may be beneficial in refractory cases 2, 8

  • Particularly useful in patients with suspected magnesium deficiency 8

• IV corticosteroids (e.g., dexamethasone 10mg) may be added for status migrainosus or to prevent recurrence 2

Important Contraindications and Precautions

• Triptans should be avoided in patients with:

  • Uncontrolled hypertension
  • Basilar or hemiplegic migraine
  • Significant cardiovascular disease 6, 1

• Opioids should be limited due to:

  • Questionable efficacy
  • Risk of dependency
  • Potential for medication overuse headache 6, 2

• Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 1

Treatment Algorithm for ED Management

1. Assess migraine severity and presence of nausea/vomiting

2. For mild to moderate migraine:

   • Start with IV/IM NSAID (e.g., ketorolac 30mg) 1, 3
   • Add antiemetic (metoclopramide 10mg or prochlorperazine 10mg IV) 1

3. For moderate to severe migraine:

   • NSAID + antiemetic + triptan (sumatriptan 6mg SC preferred for rapid onset) 3, 5
   • Consider IV fluids for hydration 2

4. For refractory migraine:

   • Consider adding IV magnesium sulfate (1-2g) 2, 8
   • Consider IV corticosteroids 2
   • DHE may be used when triptans fail or are contraindicated 6, 1

The evidence consistently shows that subcutaneous sumatriptan provides the most rapid and effective pain relief compared to other routes of administration, though with slightly higher rates of adverse events 5. Early administration of the migraine cocktail is crucial for maximum effectiveness and to prevent central sensitization 7.