Headache Cocktail for Severe Headaches
Standard IV Headache Cocktail Composition
The most effective headache cocktail for severe migraine in urgent care or emergency settings consists of IV metoclopramide 10 mg plus IV ketorolac 30 mg, administered together for rapid pain relief while minimizing side effects and rebound headache risk. 1
Primary Components
Metoclopramide 10 mg IV provides both direct analgesic effects through central dopamine receptor antagonism and treats accompanying nausea, while also enhancing absorption of co-administered medications through its prokinetic effects [1, @15@]
Ketorolac 30 mg IV (or 60 mg IM for patients under 65 years) serves as the primary NSAID component with rapid onset of action and approximately six hours of duration, making it ideal for severe migraine with minimal rebound headache risk 1
Alternative Second-Line Components
Prochlorperazine 10 mg IV can substitute for metoclopramide with comparable efficacy for headache relief, though it carries additional risks of tardive dyskinesia, hypotension, and arrhythmias 1
IV fluids for hydration should be added as dehydration worsens migraine symptoms 2
Subcutaneous sumatriptan 6 mg may be added if the patient has not already used serotonergic agents during this attack, providing 59% complete pain relief by 2 hours 2
Critical Medications to AVOID
Opioids (including hydromorphone) should NOT be included in headache cocktails as they lead to dependency, rebound headaches, and eventual loss of efficacy, particularly problematic in severe or chronic headaches 1, 2
Prednisone or corticosteroids have limited evidence for acute headache treatment and are more appropriate for status migrainosus rather than routine severe headache 1
Diphenhydramine is not recommended as part of the standard cocktail based on current evidence-based guidelines 1
Dosing Considerations and Contraindications
Ketorolac should be used with caution in patients with renal impairment (reduce dose for patients ≥65 years or 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
Triptans are contraindicated in patients with uncontrolled hypertension, coronary artery disease, or basilar/hemiplegic migraine 2
Medication Overuse Warning
Limit acute treatment to no more than 2 days per week to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily chronic headaches 1, 2, 3
If patients require acute treatment more frequently, transition to preventive therapy rather than increasing acute medication frequency 2, 3
When Oral Therapy Is Appropriate
For moderate severity headaches that don't require IV treatment:
Combination therapy: Acetaminophen 1000 mg + Aspirin 500-1000 mg + Caffeine 130 mg is more effective than single agents 3
Naproxen 500-825 mg at migraine onset, ideally when pain is still mild, can be repeated every 2-6 hours as needed (maximum 1.5 g per day) 1
Add metoclopramide 10 mg or prochlorperazine 25 mg orally 20-30 minutes before analgesics for synergistic analgesia 1