What is the typical composition of a migraine cocktail?

Typical Migraine Cocktail Composition

The standard migraine cocktail in acute care settings consists of IV ketorolac (30 mg) combined with IV metoclopramide (10 mg) or prochlorperazine (10 mg), with IV dihydroergotamine (DHE) reserved for refractory cases. 1, 2

Core Components

Primary Analgesic Agent

• Ketorolac 30 mg IV serves as the foundational NSAID component, providing rapid onset of action with approximately six hours of duration and minimal risk of rebound headache 1, 2
• For patients under 65 years without renal impairment, the standard dose is 30 mg IV or 60 mg IM 1

Antiemetic/Adjunctive Agent

• Metoclopramide 10 mg IV provides both antiemetic effects and direct analgesic properties through central dopamine receptor antagonism, offering synergistic pain relief beyond just treating nausea 1, 2
• Prochlorperazine 10 mg IV represents an equally effective alternative that relieves headache pain comparably to metoclopramide, with a slightly more favorable side effect profile (21% vs 50% adverse events compared to chlorpromazine) 1

Rescue/Refractory Agent

• Dihydroergotamine (DHE) 0.5-1.0 mg IV should be added for severe attacks unresponsive to the initial combination, with good evidence for efficacy and safety as monotherapy 3, 1, 2

Alternative Oral "Cocktail" Formulations

For Mild-to-Moderate Attacks

• Combination of aspirin 250 mg + acetaminophen 250 mg + caffeine 65 mg (available as over-the-counter Excedrin Migraine) provides synergistic analgesia with caffeine enhancing absorption and efficacy of the analgesics 3, 1
• Naproxen sodium 500-825 mg can be used as a single-agent alternative 1

For Moderate-to-Severe Attacks

• Triptan (sumatriptan 50-100 mg or rizatriptan 10 mg) combined with naproxen 500 mg demonstrates superior efficacy compared to either agent alone, with 180 more patients per 1000 achieving sustained pain relief at 48 hours 3, 2
• Triptan combined with acetaminophen 1000 mg represents an alternative combination when NSAIDs are contraindicated, though evidence is less robust than triptan-NSAID combinations 3

Administration Strategy and Timing

Initial Assessment

• Begin treatment as early as possible during the attack to improve efficacy, ideally when pain is still mild 3, 1
• Administer antiemetic 20-30 minutes before or with other medications to enhance absorption and treat gastric stasis 2

Response Evaluation

• Assess response after 30-60 minutes 2
• For inadequate response, add DHE 1 mg IV or consider subcutaneous sumatriptan 6 mg if DHE is contraindicated 2

Critical Contraindications and Cautions

Medications to Avoid

• Opioids (including hydromorphone, oxycodone, butorphanol) should be avoided as they lead to dependency, rebound headaches, and eventual loss of efficacy, with limited evidence supporting their use for migraine 1, 2
• Valproate is inferior to both metoclopramide and ketorolac, with only 4% achieving sustained headache freedom compared to 11% with metoclopramide and 16% with ketorolac 4

Cardiovascular Contraindications

• Triptans and DHE are absolutely contraindicated in patients with ischemic vascular conditions, vasospastic coronary disease, uncontrolled hypertension, or other significant cardiovascular disease 3, 2

Renal and Gastrointestinal Precautions

• Ketorolac should be used with caution in patients with renal impairment (creatinine clearance <30 mL/min), history of GI bleeding, or heart disease 1
• Reduce ketorolac dose for patients ≥65 years 1

Medication Overuse Headache Prevention

• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache, which can result from frequent use and lead to daily headaches 3, 1, 2
• If patients require acute treatment more than 2 days per week, transition to preventive therapy rather than increasing frequency of acute medications 1

Route-Specific Considerations

When to Use Non-Oral Routes

• Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours) when significant nausea or vomiting is present, though with higher adverse event rates 1
• Intranasal formulations (sumatriptan 5-20 mg or DHE nasal spray) offer alternatives for patients who cannot tolerate oral medications 3, 1

Common Pitfalls to Avoid

• Do not restrict metoclopramide only to vomiting patients - nausea itself is one of the most disabling symptoms and warrants treatment even without vomiting 1
• Do not use prednisone or corticosteroids routinely - they have limited evidence for acute headache treatment and are more appropriate for status migrainosus 1
• Do not allow patients to escalate acute medication frequency in response to treatment failure - this creates a vicious cycle of medication-overuse headache 1