Migraine Cocktail Dosing
For acute migraine treatment in the emergency department or urgent care setting, administer sumatriptan 6 mg subcutaneously (or 50-100 mg orally if subcutaneous is not available), metoclopramide 10 mg intravenously, and dexamethasone 10-24 mg intravenously or intramuscularly.
Sumatriptan Component
Subcutaneous Administration (Preferred for Rapid Relief)
- Administer 6 mg subcutaneously, which can be repeated after one hour if needed, with a maximum of 12 mg per 24 hours 1, 2
- Subcutaneous administration provides the fastest onset of action (approximately 15 minutes) and highest efficacy, with 59-80% of patients achieving pain relief within 1-2 hours 3, 4
- This route is particularly effective when nausea and vomiting are prominent features 1
Oral Administration (Alternative)
- Administer 50-100 mg orally, which can be repeated after 2 hours if needed, with a maximum of 200 mg per 24 hours 1, 2
- The 100 mg dose is more effective than 50 mg for pain-free response at 2 hours (NNT 4.7 vs 6.1) 5
- Oral administration reaches peak concentration in 2-3 hours 1
Intranasal Administration (Alternative)
- Administer 5-10 mg (one to two sprays) in one nostril, which can be repeated after 2 hours, with a maximum of 40 mg per day 1, 2
- Consider this route when oral administration is not feasible due to nausea or vomiting 1
Metoclopramide Component
- Administer 10 mg intravenously as both an antiemetic and as monotherapy for acute migraine 1
- Metoclopramide has fair evidence supporting its use as monotherapy for acute migraine attacks, particularly when nausea and vomiting are present 1
- The sedating side effect may be beneficial in the acute setting 1
Dexamethasone Component
While the provided evidence does not specify exact dexamethasone dosing for migraine cocktails, standard practice typically uses 10-24 mg IV/IM. Note that the evidence states "intravenous corticosteroids" were studied but "are not effective" as monotherapy 1, though they are commonly used in clinical practice to prevent headache recurrence.
Critical Contraindications
Do not administer sumatriptan in patients with: 1, 2, 6
- Coronary artery disease or risk factors for heart disease
- Uncontrolled hypertension
- Hemiplegic or basilar migraine
- Recent use (within 24 hours) of ergotamine-containing medications or another triptan
- Concurrent MAOI use
- Pregnancy (use only under strict specialist supervision)
- Impaired hepatic function
Important Clinical Considerations
Trial Period
- Patients should try sumatriptan for 2-3 headache episodes before abandoning this therapy, as response can vary between attacks 1, 2
- If one triptan fails, consider switching to a different triptan (naratriptan, rizatriptan, zolmitriptan, almotriptan, eletriptan, or frovatriptan) 1, 7
Frequency Limitations
- Limit acute migraine treatment to no more than twice per week to prevent medication-overuse headache 1
- Approximately 40% of patients experience headache recurrence within 24 hours, which can be treated with a second dose 1, 8
Common Adverse Events
- Subcutaneous administration causes injection site reactions in approximately 30% of patients 2, 4
- Chest pressure and heaviness occur in 3-5% of patients but true ischemic events are rare 1, 4
- Other common effects include nausea, warmth, vomiting, vertigo, and malaise 1, 2