What are the typical ingredients of a migraine cocktail for acute migraine treatment?

Migraine Cocktail Ingredients

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

Core Components by Setting

Emergency Department/Urgent Care Standard Cocktail

• Ketorolac (Toradol) 30-60mg IV/IM serves as the primary NSAID component, providing rapid onset analgesia with approximately 6 hours duration and minimal rebound headache risk 1, 2
• Metoclopramide 10mg IV provides both antiemetic effects and direct analgesic properties through central dopamine receptor antagonism, plus enhances absorption of co-administered medications through prokinetic effects 1, 2
• Prochlorperazine 10mg IV represents an equally effective alternative to metoclopramide, with comparable efficacy for headache relief and nausea control 1, 2
• IV fluids for hydration are routinely included as part of the standard cocktail 2

Refractory or Severe Cases - Add Second-Line Agent

• Dihydroergotamine (DHE) 1mg IV or intranasal should be added for severe or refractory migraines that don't respond to the initial cocktail within 30-60 minutes 3, 2
• Sumatriptan 6mg subcutaneous serves as an alternative if DHE is contraindicated, providing the highest efficacy among triptans with 59% achieving complete pain relief by 2 hours 1, 4

Outpatient/Oral Migraine Cocktail Options

Mild to Moderate Attacks

• Aspirin 500-1000mg + Acetaminophen 500-1000mg + Caffeine 130mg represents the evidence-based combination analgesic with proven efficacy 3, 5
• Naproxen sodium 500-825mg or Ibuprofen 400-800mg as single-agent NSAIDs with strong evidence 3, 5
• Metoclopramide 10mg orally or Prochlorperazine 25mg orally given 20-30 minutes before the NSAID enhances absorption and provides synergistic analgesia 2

Moderate to Severe Attacks

• Sumatriptan 50-100mg orally or other oral triptans (rizatriptan, eletriptan, zolmitriptan) as the primary agent 3, 5
• Fast-acting NSAID (naproxen sodium 500mg or ibuprofen 600mg) combined with the triptan prevents headache recurrence, which occurs in 40% of patients within 48 hours 1
• Antiemetic (metoclopramide 10mg or prochlorperazine 25mg) added for nausea or to enhance medication absorption 2, 5

Route-Specific Considerations for Nausea/Vomiting

• Subcutaneous sumatriptan 6mg provides the most rapid and effective relief when oral route is compromised, with 70-80% achieving relief within 1 hour 3, 4
• Intranasal sumatriptan 20mg or intranasal DHE serve as alternatives when injection is not preferred 3, 5
• Rectal prochlorperazine 25mg can be used when oral and parenteral routes are not feasible 2

Critical Components to AVOID

• Opioids (hydromorphone, oxycodone) should NOT be included in migraine cocktails as they lead to dependency, medication-overuse headache, and loss of efficacy, with only butorphanol nasal spray having any supporting evidence 3, 1
• Corticosteroids (prednisone, dexamethasone) have limited evidence for acute migraine treatment and are more appropriate for status migrainosus rather than routine cocktails 1
• Diphenhydramine is not recommended as a standard component despite common use 1

Timing and Frequency Restrictions

• Administer medications as early as possible during the attack while pain is still mild to maximize efficacy 1, 5
• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache, which develops from frequent use and leads to daily headaches 3, 1, 2
• Assess response after 30-60 minutes before adding second-line agents like DHE or subcutaneous sumatriptan 2

Contraindications That Alter Cocktail Selection

• Triptans and DHE are absolutely contraindicated in patients with ischemic heart disease, uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 3, 2
• Ketorolac requires caution in patients with renal impairment (CrCl <30 mL/min), history of GI bleeding, or heart disease 1
• Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 1
• Prochlorperazine carries additional risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias, and is contraindicated with CNS depression or adrenergic blocker use 1

Common Pitfall to Avoid

The most critical error is allowing patients to escalate frequency of acute medication use when treatments seem less effective—this creates medication-overuse headache rather than solving the problem. Instead, transition to preventive therapy while optimizing the acute treatment strategy. 1