What is the recommended migraine cocktail for inpatients?

Inpatient Migraine Cocktail

For inpatients with acute severe migraine, administer IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy, which provides rapid pain relief while minimizing side effects and risk of rebound headache. 1

First-Line IV Combination Components

Primary Analgesic

• Ketorolac 30 mg IV is the preferred parenteral NSAID with relatively rapid onset of action and approximately 6 hours duration, making it ideal for severe migraine abortive therapy with minimal risk of rebound headache 1
• For patients ≥65 years or with renal impairment, reduce the ketorolac dose 1
• Ketorolac should be used with caution in patients with renal impairment, history of GI bleeding, or heart disease 1

Antiemetic with Synergistic Analgesia

• Metoclopramide 10 mg IV provides not only treatment for accompanying nausea but also delivers synergistic analgesia for migraine pain through central dopamine receptor antagonism 1, 2
• Metoclopramide's prokinetic effects help overcome gastric stasis during migraine attacks, enhancing absorption of co-administered medications 1
• Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, and GI obstruction 1

Alternative Antiemetic

• Prochlorperazine 10 mg IV effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy 1
• Prochlorperazine has a more favorable side effect profile than chlorpromazine, with adverse events reported in 21% versus 50% 1
• Prochlorperazine has additional risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias, and is contraindicated in CNS depression and use of adrenergic blockers 1

Second-Line Options for Refractory Cases

For Inadequate Response After 30-60 Minutes

• Dihydroergotamine (DHE) 1 mg IV has good evidence for efficacy and safety as monotherapy for acute migraine attacks and can be added for severe or refractory migraines 3, 1, 4
• DHE is contraindicated in patients with uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 4

Alternative Triptan Option

• Sumatriptan 6 mg subcutaneously provides the highest efficacy among triptans, with 59% achieving complete pain relief by 2 hours, and can be used if DHE is contraindicated 1, 5, 6
• Sumatriptan is most effective when administered early in the attack, when headache is still mild 3
• Triptans are contraindicated in patients with ischemic heart disease, uncontrolled hypertension, or other significant cardiovascular disease 4

Administration Strategy and Timing

• Begin treatment as early as possible during the attack to improve efficacy 3, 1
• Assess response after 30-60 minutes 4
• For inadequate response, add DHE 1 mg IV or sumatriptan 6 mg subcutaneously if DHE is contraindicated 4
• Non-oral routes of administration are preferred when significant nausea or vomiting is present 3, 1

Critical Pitfalls to Avoid

Medication Overuse Headache

• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache, which can result from frequent use of acute medications 3, 1, 4
• Be cautious about potential medication overuse headache, particularly in patients who frequently visit for migraine treatment 4

Contraindicated Medications

• Do not use opioids or butalbital for migraine treatment, as they can lead to dependency, rebound headaches, and eventual loss of efficacy 3, 1, 4
• Avoid establishing a pattern of frequent opioid use for headache management 1

Drug Interactions

• Sumatriptan and DHE must not be given together with vasoconstrictive substances (e.g., ergotamines) or with migraine prophylactics with similar properties (e.g., methysergide) 7
• Do not administer triptans during the migraine aura phase 7

Discharge Planning and Follow-Up

• Provide oral rescue medications for use at home, typically including an NSAID and an antiemetic 4
• If headaches continue to impair quality of life despite optimized acute therapy, or if the patient uses acute medications more than 2 days per week, preventive therapy is indicated 1
• Educate patients about lifestyle modifications including hydration, regular meals, sufficient sleep, and stress management 4
• Consider preventive therapy referral for patients with frequent admissions for migraine 4