What does a migraine cocktail typically consist of in an Emergency Room (ER) setting?

Migraine Cocktail Components in the Emergency Room

The most effective ER migraine cocktail consists of IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy, with prochlorperazine 10 mg IV as an equally effective alternative to metoclopramide. 1, 2

Core Components

Primary Agents (Choose One Dopamine Antagonist)

• Metoclopramide 10 mg IV provides both antiemetic effects and synergistic analgesia for migraine pain, making it the most commonly recommended dopamine antagonist 1, 2, 3
• Prochlorperazine 10 mg IV is equally effective to metoclopramide for headache relief and has demonstrated >70% efficacy in multiple studies 1, 3, 4
• Both agents work as monotherapy but are more effective when combined with NSAIDs 3

NSAID Component

• Ketorolac 30-60 mg IV/IM serves as the primary NSAID with rapid onset (approximately 6 hours duration) and minimal rebound headache risk 1, 2
• Use 30 mg IV for patients ≥65 years or with renal impairment; 60 mg IM for younger patients without contraindications 1

Alternative and Add-On Agents

When First-Line Fails

• Dihydroergotamine (DHE) parenteral or intranasal formulations for severe, refractory cases 5, 1, 2
• Magnesium sulfate 1 gram IV showed superior pain reduction compared to ketorolac alone in head-to-head trials 6
• Dexamethasone 8 mg IV combined with metoclopramide achieved equivalent 2-hour pain relief to ketorolac, though with slower onset 7

Migraine-Specific Agents

• Subcutaneous sumatriptan for severe presentations when oral route is compromised by nausea/vomiting 5, 1, 2
• Triptans should be administered early in the attack for maximum efficacy 1, 2

What NOT to Include

• Avoid opioids (including meperidine/pethidine) as they lead to dependency, rebound headaches, and are inferior to dopamine antagonists 1, 8, 3
• Avoid diphenhydramine as a routine component unless specifically preventing extrapyramidal side effects from high-dose phenothiazines 1
• Prednisone has limited evidence for acute treatment and is more appropriate for status migrainosus 1

Administration Algorithm

For typical acute migraine in ER:

1. Start with metoclopramide 10 mg IV + ketorolac 30 mg IV simultaneously 1, 2
2. Reassess at 1 hour; if inadequate response, add magnesium sulfate 1 gram IV or DHE 6
3. If nausea predominates, prochlorperazine 10 mg IV can replace metoclopramide with equivalent efficacy 1, 3

For severe/refractory presentations:

1. Consider dexamethasone 8 mg IV + metoclopramide 10 mg IV for longer-lasting effect 7
2. Add subcutaneous sumatriptan if vascular headache features predominate 2, 4

Critical Cautions

• Akathisia risk is highest with droperidol and prochlorperazine; consider prophylactic diphenhydramine only if using high doses 3
• Limit acute treatment to ≤2 times weekly to prevent medication-overuse headache 1, 8
• Ketorolac contraindications include renal impairment, GI bleeding history, and significant cardiovascular disease 1
• Metoclopramide contraindications include pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 1
• Avoid triptans in uncontrolled hypertension, coronary artery disease, or basilar/hemiplegic migraine 2