What medications are typically included in a migraine cocktail for treatment?

Migraine Cocktail Medications

The most effective migraine cocktail for acute treatment in urgent care or emergency settings combines IV ketorolac 30mg, IV metoclopramide 10mg (or prochlorperazine 10mg), and IV fluids, with dihydroergotamine (DHE) reserved for refractory cases. 1, 2

Standard Migraine Cocktail Components

First-Line IV Combination

• Ketorolac 30mg IV serves as the primary analgesic with rapid onset (approximately 6 hours duration) and minimal rebound headache risk 1, 2
• Metoclopramide 10mg IV provides dual benefit: treats nausea while delivering synergistic analgesia for migraine pain 1, 2
• Prochlorperazine 10mg IV is equally effective as metoclopramide for both headache relief and nausea, offering comparable efficacy 1, 2
• IV fluids for hydration support the overall treatment response 2

For Refractory or Severe Cases

• Dihydroergotamine (DHE) 1mg IV should be added after 30-60 minutes if initial cocktail provides inadequate response 2
• DHE is available in intranasal formulation as an alternative to IV administration 1, 3

Oral Migraine Cocktail Options

Mild to Moderate Attacks

• NSAIDs (ibuprofen 400-800mg, naproxen sodium, or aspirin) as first-line agents 1, 2
• Combination therapy with acetaminophen + aspirin + caffeine enhances efficacy through synergistic analgesia 1, 3
• Antiemetic (metoclopramide 10mg orally or prochlorperazine 25mg) administered 20-30 minutes before or with other medications 2

Moderate to Severe Attacks

• Triptans (sumatriptan 50-100mg orally, rizatriptan 10mg, or zolmitriptan 2.5-5mg) as first-line for moderate-severe attacks 1, 2
• Sumatriptan 6mg subcutaneous provides the most rapid and effective relief, with 59% achieving complete pain relief by 2 hours (NNT 2.3) 4
• Intranasal sumatriptan (5-20mg) or nasal spray triptans are preferred when significant nausea/vomiting is present 5, 1

Critical Administration Principles

Timing and Dosing Strategy

• Begin treatment as early as possible during the attack to maximize efficacy 1, 2
• Assess response after 30-60 minutes before adding additional agents 2
• Non-oral routes (IV, subcutaneous, intranasal) are preferred when nausea or vomiting is prominent 1

Medication Overuse Prevention

• Limit acute therapy to no more than 2 days per week to prevent medication-overuse headache 1, 2
• Frequent use (>15 days/month for most medications, >10 days/month for triptans) leads to rebound headaches 3

Important Contraindications and Cautions

Absolute Contraindications

• Triptans and DHE are contraindicated in ischemic heart disease, uncontrolled hypertension, basilar or hemiplegic migraine, and significant cardiovascular disease 2, 6
• Ketorolac requires caution in renal impairment, GI bleeding history, or heart disease 2
• Metoclopramide is contraindicated in pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 1

Medications to Avoid

• Opioids (including hydromorphone) should be avoided as they lead to dependency, rebound headaches, and loss of efficacy 1, 2
• Butalbital-containing compounds carry similar risks and should not be used routinely 3, 2
• Prednisone has limited evidence for acute headache treatment and is more appropriate for status migrainosus 1

Alternative Agents for Special Circumstances

When NSAIDs and Triptans Are Contraindicated

• CGRP antagonists (rimegepant, ubrogepant, zavegepant) as first-line alternatives 3
• Lasmiditan (ditan class) for moderate-severe attacks when other options fail 3
• Dihydroergotamine intranasal formulation with good safety profile 3

Adjunctive Considerations

• Caffeine enhances absorption and provides synergistic analgesia when combined with analgesics 1
• Corticosteroids are reserved for status migrainosus (continuous migraine lasting up to one week) rather than routine acute treatment 1, 3

Route-Specific Efficacy

Subcutaneous Administration

• Sumatriptan 6mg subcutaneous provides the highest efficacy (59% pain-free at 2 hours vs 15% placebo, NNT 2.3) but with higher adverse event rates 4, 7

Oral Administration

• Oral sumatriptan 100mg achieves 28% pain-free at 2 hours vs 11% placebo (NNT 6.1) 4
• Rizatriptan 10mg has faster onset than other oral triptans with therapeutic gain of 37% 7

Intranasal Administration

• Intranasal sumatriptan 20mg provides NNT 3.5 for headache relief at 2 hours 4