Migraine Cocktail in the Emergency Department
Standard ED Migraine Cocktail Components
The most effective ED migraine cocktail consists of IV metoclopramide 10 mg plus IV ketorolac 30 mg, which provides rapid pain relief while minimizing side effects and rebound headache risk. 1
Primary Agents
- Dopamine antagonists are the cornerstone of ED migraine treatment, with prochlorperazine 10 mg IV and metoclopramide 10 mg IV demonstrating superior or equivalent efficacy to all other medication classes 2, 3
- Prochlorperazine and droperidol show the highest efficacy rates but carry increased risk of akathisia 2, 3
- Metoclopramide provides dual benefit by treating both headache pain and nausea through synergistic analgesia 1, 4
NSAID Component
- Ketorolac 30 mg IV is the preferred parenteral NSAID with rapid onset (approximately 6 hours duration) and minimal rebound headache risk 1, 4
- Reduce dose for patients ≥65 years or with renal impairment 1
- Contraindications include renal impairment, GI bleeding history, and heart disease 1
Alternative Migraine-Specific Agents
- Parenteral dihydroergotamine (DHE) can be added for severe, refractory cases, showing equivalent efficacy to dopamine antagonists 4, 3
- DHE is particularly useful when other treatments have failed 5, 4
Administration Strategy
- Treat as early as possible during the attack to maximize efficacy 1, 4
- Use non-oral routes when significant nausea or vomiting is present 5, 4
- Avoid combination with diphenhydramine unless specifically needed for akathisia prophylaxis, as it is not part of standard evidence-based cocktails 1
What to Avoid
- Opioids should be avoided as they lead to dependency, rebound headaches, and eventual loss of efficacy 1, 4, 6
- Meperidine was inferior to chlorpromazine and only equivalent to other neuroleptics 2, 3
- Corticosteroids (like prednisone) have limited evidence for acute treatment and are more appropriate for preventing recurrence after discharge rather than immediate pain relief 1
Critical Pitfalls
- Medication-overuse headache results from frequent use of acute medications more than twice weekly, leading to increasing headache frequency and potentially daily headaches 5, 4
- Metoclopramide is contraindicated in pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 1
- Prochlorperazine carries additional risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias 1
Evidence Quality
The dopamine antagonist + NSAID combination represents the highest quality evidence for ED migraine treatment, with prochlorperazine and metoclopramide being the most extensively studied medications in emergent settings 2, 3. When metoclopramide is combined with diphenhydramine, it demonstrates superiority over triptans and NSAIDs alone 2, 3. However, the standard cocktail of metoclopramide plus ketorolac without diphenhydramine provides optimal balance of efficacy and tolerability 1.