What is the composition and usage of a migraine cocktail for treating migraines?

Migraine Cocktail Composition and Usage

The most effective IV migraine cocktail for acute severe migraine consists of metoclopramide 10 mg IV plus ketorolac 30 mg IV, which provides rapid pain relief while minimizing side effects and rebound headache risk. 1

Standard IV Migraine Cocktail Components

First-Line Combination

• Metoclopramide 10 mg IV provides both antiemetic effects and direct analgesic action through central dopamine receptor antagonism, offering synergistic pain relief beyond just treating nausea 1
• Ketorolac 30 mg IV (or 60 mg IM for patients under 65 years) delivers rapid onset NSAID analgesia with approximately 6 hours duration and minimal rebound headache risk 1
• This combination should be administered as first-line therapy for severe migraine attacks requiring intravenous treatment 1

Alternative Antiemetic Option

• Prochlorperazine 10 mg IV can substitute for metoclopramide with comparable efficacy for headache relief, though it carries additional risks of tardive dyskinesia, hypotension, tachycardia, and arrhythmias 1
• Prochlorperazine has a more favorable side effect profile than chlorpromazine (21% vs 50% adverse events) 1

Route-Specific Treatment Options

Oral Therapy for Mild-to-Moderate Attacks

• NSAIDs are first-line: aspirin 650-1000 mg, ibuprofen 400-800 mg, or naproxen sodium 500-825 mg 1
• Combination therapy with aspirin plus acetaminophen plus caffeine shows enhanced efficacy when NSAIDs alone provide inadequate relief 1
• Triptans (sumatriptan 50-100 mg, rizatriptan, zolmitriptan, naratriptan) escalate to first-line for moderate-to-severe attacks 1, 2

Subcutaneous Route for Maximum Efficacy

• Sumatriptan 6 mg subcutaneous provides the highest efficacy with 59% achieving complete pain relief by 2 hours, though with higher adverse event rates 1, 3
• This route is particularly useful for patients with rapid peak intensity, vomiting, or failed oral therapy 1

Intranasal Options

• Sumatriptan 5-20 mg intranasal or dihydroergotamine (DHE) intranasal are effective when significant nausea or vomiting prevents oral administration 1
• DHE has good evidence for efficacy and safety as monotherapy, with no rebound headache risk 1, 4

Critical Timing and Administration Principles

• Administer treatment as early as possible during the attack while pain is still mild to maximize efficacy 1
• Select non-oral routes when significant nausea or vomiting is present early in the attack 1
• Limit acute therapy to no more than twice weekly to prevent medication-overuse headache, which can lead to daily headaches 1

Medications to Avoid in Migraine Cocktails

• Opioids (including hydromorphone) should be reserved only when other medications cannot be used, sedation is not a concern, and abuse risk has been addressed, as they lead to dependency, rebound headaches, and loss of efficacy 1
• Ergotamine is now third-line therapy due to higher rebound headache risk and inferior tolerability compared to triptans and NSAIDs 4
• Diphenhydramine is not recommended as a routine component unless needed to prevent extrapyramidal side effects from prochlorperazine 1

Dosing Adjustments and Contraindications

Ketorolac Precautions

• Use reduced doses (15 mg IV) in patients ≥65 years or with renal impairment 1
• Contraindicated in renal impairment (CrCl <30 mL/min), history of GI bleeding, or active cardiovascular disease 1

Metoclopramide Contraindications

• Avoid in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 1

Triptan Contraindications

• Absolute contraindications include coronary artery disease, coronary vasospasm, Wolff-Parkinson-White syndrome, stroke history, hemiplegic or basilar migraine, peripheral vascular disease, ischemic bowel disease, and uncontrolled hypertension 2
• Cannot use within 24 hours of ergotamine-containing medications 2

When to Escalate or Add Preventive Therapy

• If headaches occur more than 2 days per week despite optimized acute treatment, initiate preventive therapy rather than increasing frequency of acute medications 1
• If a patient's current migraine medication stops working, try a different triptan before escalating to third-line agents, as failure of one triptan does not predict failure of others 1
• Rule out medication-overuse headache if using acute medications more than twice weekly 1