What is the initial treatment for a patient with a migraine headache and a normal physical exam?

Migraine Headache Cocktail for Normal Exam

For a patient with acute migraine and normal physical exam, administer IV metoclopramide 10 mg plus IV ketorolac 30 mg as first-line combination therapy. 1

First-Line IV Cocktail Components

Metoclopramide 10 mg IV:

• Provides direct analgesic effects through central dopamine receptor antagonism, not just antiemetic action 1
• Enhances gastric motility which is impaired during migraine attacks, improving absorption of co-administered medications 1
• Effective for both headache pain and accompanying nausea 1

Ketorolac 30 mg IV:

• Rapid onset of action with approximately 6-hour duration 2
• Minimal risk of rebound headache compared to other analgesics 2
• Reserved for severe migraine abortive therapy 2

Alternative IV Options if First-Line Fails

Prochlorperazine 10 mg IV:

• Comparable efficacy to metoclopramide for headache relief 1
• More favorable side effect profile than chlorpromazine (21% vs 50% adverse events) 1
• Can be substituted if metoclopramide is contraindicated 1

Dihydroergotamine (DHE) 0.5-1.0 mg IV:

• Good evidence for efficacy and safety as monotherapy 1, 3
• Consider for refractory cases not responding to initial cocktail 3

Critical Contraindications to Screen For

Ketorolac contraindications:

• Renal impairment (creatinine clearance <30 mL/min) 1
• History of GI bleeding 1
• Active cardiovascular disease 1

Metoclopramide contraindications:

• Pheochromocytoma 1
• Seizure disorder 1
• GI bleeding or obstruction 1

Prochlorperazine additional risks:

• CNS depression 1
• Use of adrenergic blockers 1
• Risk of tardive dyskinesia, hypotension, tachycardia 1

Medication-Overuse Headache Prevention

• Limit acute treatment to no more than twice weekly to prevent medication-overuse headache 2, 1
• If patient requires acute treatment more than 2 days per week, initiate preventive therapy 1
• Avoid establishing patterns of frequent opioid or barbiturate use 2

Dosing Adjustments

For patients ≥65 years or renal impairment:

• Reduce ketorolac dose appropriately 1

Maximum duration:

• Ketorolac should not exceed 5 days of total use 1

What NOT to Include

Avoid opioids (hydromorphone, meperidine):

• Lead to dependency, rebound headaches, and loss of efficacy 2, 1
• Reserved only when other medications cannot be used and abuse risk addressed 1

Avoid diphenhydramine:

• No evidence supporting its use in acute migraine treatment 1
• Not recommended in current guidelines 1, 3

Avoid corticosteroids (prednisone):

• Limited evidence for acute migraine treatment 1
• More appropriate for status migrainosus than routine acute headache 1

Administration Timing

• Administer as early as possible during the attack to improve efficacy 2, 1
• Non-oral routes preferred when significant nausea or vomiting present 1, 3

Expected Response

• Most patients should experience significant relief within 30-60 minutes of IV administration 1
• If no response after 2 hours, consider adding DHE or alternative therapy 3