What is a typical migraine cocktail?

Typical Migraine Cocktail Components

A typical migraine cocktail combines an NSAID (such as ketorolac 30-60mg IV or ibuprofen 400-800mg oral) with an antiemetic (metoclopramide 10mg IV or prochlorperazine 10mg IV), and may include caffeine or a triptan depending on severity. 1

Outpatient/Oral Migraine Cocktail

For Mild to Moderate Attacks

• Start with an NSAID as the foundation: aspirin 650-1000mg, ibuprofen 400-800mg, or naproxen sodium 275-550mg 1
• Add an antiemetic: metoclopramide 10mg oral or prochlorperazine 25mg oral (treats nausea and provides synergistic analgesia) 1
• Consider adding caffeine: combination analgesics containing acetaminophen-aspirin-caffeine are effective, though acetaminophen alone is ineffective 1

For Moderate to Severe Attacks

• Use a triptan as the primary agent: sumatriptan, rizatriptan, naratriptan, or zolmitriptan 1
• Combine with an NSAID: the combination of triptan plus NSAID provides enhanced efficacy over either alone 1
• Add an antiemetic: metoclopramide or prochlorperazine for nausea and additional analgesic benefit 1

Emergency Department/IV Migraine Cocktail

First-Line IV Combination

• Metoclopramide 10mg IV (primary agent providing both antiemetic and direct analgesic effects) 1, 2
• Ketorolac 30-60mg IV (rapid onset NSAID with approximately 6 hours duration and minimal rebound risk) 1, 2
• Alternative antiemetic: prochlorperazine 10mg IV (comparable efficacy to metoclopramide) 1, 2

For Severe Refractory Cases

• Dihydroergotamine (DHE) may be added parenterally or as nasal spray for severe migraines not responding to standard cocktail 1, 3
• Avoid opioids when possible due to risk of dependency and rebound headaches 1, 2

Route Selection Based on Symptoms

When Significant Nausea/Vomiting Present

• Subcutaneous sumatriptan 6mg (highest efficacy: 59% pain-free at 2 hours) 2
• Intranasal options: sumatriptan 5-20mg or zolmitriptan nasal spray 1, 2
• Rectal suppositories: prochlorperazine 25mg 1
• IV administration: metoclopramide plus ketorolac 1, 2

Critical Timing and Administration Principles

• Administer as early as possible during the attack to improve efficacy—ideally when pain is still mild 1, 2
• Antiemetics should be given 20-30 minutes before analgesics to enhance absorption and provide synergistic benefit 2

Contraindications and Safety Considerations

Triptan Contraindications

• Absolute contraindications: uncontrolled hypertension, coronary artery disease, basilar/hemiplegic migraine 1
• Use with caution in patients with cardiovascular risk factors 4

DHE Contraindications

• Cannot be used with triptans, pregnancy/lactation, coronary artery disease, uncontrolled hypertension, or MAOIs within 14-15 days 3

Ketorolac Precautions

• Use with caution in renal impairment (reduce dose in patients ≥65 years), history of GI bleeding, or heart disease 2

Medication Overuse Headache Prevention

• Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache 1, 2
• Medications that cause rebound: ergotamine, opiates, triptans, and analgesics containing butalbital, caffeine, or isometheptene 1
• If using acute medications more frequently, initiate preventive therapy rather than increasing acute medication frequency 2

Treatment Escalation Algorithm

Step 1: Initial Treatment Failure

• If NSAID fails after 3 consecutive attacks: switch to a triptan 4
• If one triptan fails: try a different triptan (failure of one does not predict failure of others) 2

Step 2: All Triptans Failed

• Consider ditans or gepants as third-line agents 4, 2
• Try combination therapy: NSAID plus triptan for enhanced efficacy 1

Step 3: Refractory Cases

• Parenteral DHE in emergency settings 1, 3
• Initiate preventive therapy if adversely affected ≥2 days per month despite optimized acute treatment 4

What NOT to Include

• Avoid opioids (hydromorphone, oxycodone) except as absolute last resort when other medications contraindicated and abuse risk addressed 2
• Avoid butalbital-containing compounds due to high risk of medication-overuse headache 1
• Prednisone has limited evidence for acute migraine treatment and is not part of standard cocktails 2
• Lorazepam has limited evidence for acute headache treatment 2