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

Standard Migraine Cocktail 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 cases, with non-oral routes preferred when nausea or vomiting is present. 1, 2, 3

First-Line Medications

• NSAIDs are recommended as first-line treatment for most patients with migraines in the ED, with proven efficacy for aspirin, ibuprofen, naproxen sodium, and the acetaminophen-aspirin-caffeine combination 1
• Intravenous ketorolac is commonly used in the ED setting for its rapid onset of action 2
• Acetaminophen alone is ineffective for migraine treatment and should not be used as monotherapy 1

Antiemetics

• Metoclopramide not only treats nausea but also improves gastric motility which may be impaired during migraine attacks 1, 3
• Prochlorperazine can effectively relieve both headache pain and nausea 3
• Antiemetics should be used even when nausea is present without vomiting 3
• Intravenous metoclopramide may be an appropriate choice as monotherapy for acute attacks, particularly in patients with nausea and vomiting 4

Migraine-Specific Medications

• Triptans are recommended for moderate to severe migraine attacks or when NSAIDs provide inadequate relief 2, 3
• Subcutaneous sumatriptan is the most effective triptan formulation, with pain reduced from moderate/severe to none in almost 6 in 10 people (59%) compared to placebo (15%) 5
• Subcutaneous sumatriptan has a very rapid onset of action, making it ideal for emergency settings 4
• Other triptans with good evidence for efficacy include oral naratriptan, rizatriptan, and zolmitriptan 1

Route of Administration Considerations

• For patients with significant nausea or vomiting, non-oral routes of administration are preferred 1, 3, 6
• Options include subcutaneous injection (sumatriptan), intranasal sprays (sumatriptan, zolmitriptan), and rectal suppositories 6
• Subcutaneous administration provides more rapid pain relief than other routes, with a median time to meaningful relief of 34 minutes 7, 5
• Orally disintegrating tablets (rizatriptan, zolmitriptan) are useful alternatives for patients who have difficulty swallowing pills 6

Treatment Algorithm for ED Management

1. Initial Assessment:

   • Evaluate for red flags indicating secondary headache requiring different management 2
   • Determine severity of migraine attack and presence of nausea/vomiting 1, 2

2. For Mild to Moderate Migraine:

   • Start with IV NSAIDs (typically ketorolac 30mg IV) 1, 2
   • Add an antiemetic (metoclopramide 10mg IV or prochlorperazine 10mg IV) 1, 3

3. For Moderate to Severe Migraine:

   • Use the combination of IV NSAIDs plus antiemetics 2, 3
   • Add a triptan (preferably subcutaneous sumatriptan 6mg) if no contraindications exist 1, 5

4. For Refractory Migraine:

   • Consider intravenous dihydroergotamine (DHE) 0.5-1.0 mg 4
   • IV corticosteroids may be beneficial for preventing recurrence 2

Important Contraindications and Precautions

• Triptans should not be used in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or those at risk for heart disease 4, 1
• Ergotamines are contraindicated with concurrent triptan use, beta blockers, antihypertensives, SSRIs, macrolides, and in patients with coronary artery disease or hypertension 4
• Opioids should be limited due to questionable efficacy, adverse effects, and risk of dependency 1, 2, 8
• Limit acute treatments to no more than twice weekly to prevent medication-overuse headache 4, 1

Discharge Considerations

• Oral sumatriptan (100 mg) is effective in treating headache recurrence within 24 hours after ED discharge 7
• Consider preventive therapy if patient experiences frequent attacks (generally ≥2 attacks per month) 2