What is the recommended initial approach for managing acute headache in the Emergency Room (ER), specifically the composition of a headache cocktail?

Headache Cocktail in the Emergency Room

For acute migraine in the ER, administer IV metoclopramide 10 mg plus IV ketorolac 30 mg as the first-line headache cocktail, which provides rapid pain relief through complementary mechanisms while minimizing rebound headache risk. 1

First-Line IV Cocktail Components

Metoclopramide 10 mg IV

• Provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties 1
• Addresses gastric stasis during migraine attacks, enhancing absorption of co-administered medications 1
• Demonstrated superiority over ketorolac and valproate in randomized trials, with mean pain improvement of 4.7 points on a 0-10 scale at 60 minutes 2
• Only 33% of patients required rescue medication compared to 52% with ketorolac alone 2

Ketorolac 30 mg IV

• Rapid onset of action with approximately 6 hours duration, making it ideal for severe migraine with minimal rebound headache risk 1
• Provides sustained analgesia beyond the immediate ED visit 1
• Mean pain improvement of 3.9 points at 60 minutes in comparative trials 2

Administration Protocol

Administer both medications concurrently as an IV drip over 15 minutes to optimize efficacy 2. The combination provides:

• Synergistic analgesia through different mechanisms (dopamine antagonism + prostaglandin inhibition) 1
• Treatment of nausea while simultaneously addressing pain 1, 3
• Lower rescue medication requirements than monotherapy 2

Alternative IV Options for Specific Scenarios

When NSAIDs are Contraindicated

• Metoclopramide 10 mg IV as monotherapy is appropriate and effective 3, 2
• Consider adding IV dihydroergotamine (DHE) 0.5-1.0 mg for refractory cases 3, 4

For Patients with Cardiovascular Contraindications

• Prochlorperazine 10 mg IV is comparable to metoclopramide in efficacy and relieves both headache pain and nausea 1
• Avoid triptans in patients with uncontrolled hypertension, ischemic vascular disease, or significant cardiovascular disease 3, 4

For Rapid-Onset Severe Migraine

• Subcutaneous sumatriptan 6 mg provides the highest efficacy with onset within 15 minutes, achieving pain relief in 70-82% of patients 1
• Achieves complete pain relief in 59% by 2 hours, superior to all other routes 1

Critical Contraindications and Precautions

Ketorolac Contraindications

• Renal impairment (creatinine clearance <30 mL/min) 1
• Active GI bleeding or history of peptic ulcer disease 1
• Aspirin/NSAID-induced asthma 1

Metoclopramide Contraindications

• Pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 1
• Monitor for akathisia: 6% of patients report feeling "very restless" after administration 2

Prochlorperazine Additional Risks

• Tardive dyskinesia, hypotension, tachycardia, and arrhythmias 1
• Contraindicated in CNS depression and with adrenergic blockers 1

Medication-Overuse Headache Prevention

Strictly limit all acute migraine medications to no more than 2 days per week to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches 1, 3, 4. If patients require acute treatment more frequently:

• Initiate preventive therapy immediately rather than increasing acute medication frequency 1
• NSAIDs and triptans trigger medication-overuse headache at ≥15 days/month and ≥10 days/month, respectively 1

Rescue Medication for Treatment Failure

If the initial cocktail fails after 60-120 minutes:

• Administer IV DHE 0.5-1.0 mg for refractory migraine 3, 4
• Consider subcutaneous sumatriptan 6 mg if not previously given and no cardiovascular contraindications exist 1
• Avoid opioids due to risk of dependency, rebound headaches, and eventual loss of efficacy 1, 4

Discharge Planning

Oral Outpatient Cocktail

Prescribe sumatriptan 50-100 mg PLUS naproxen sodium 500 mg for home treatment of future moderate to severe migraine attacks 1. This combination:

• Provides 130 more patients per 1000 achieving sustained pain relief at 48 hours compared to either agent alone 1
• Represents the strongest recommendation from current guidelines 1

When to Initiate Preventive Therapy

Preventive therapy is indicated when patients experience 1, 4:

• Two or more attacks per month producing disability lasting 3+ days
• Use of abortive medication more than twice per week
• Contraindication to or failure of acute treatments
• Presence of uncommon migraine conditions (hemiplegic migraine, prolonged aura, migrainous infarction)

First-line preventive agents include propranolol 80-240 mg/day, timolol 20-30 mg/day, or topiramate 4.

Common Pitfalls to Avoid

• Do not withhold metoclopramide until vomiting occurs: nausea itself is one of the most disabling symptoms and warrants treatment even without vomiting 1
• Do not use acetaminophen alone: it is ineffective for migraine treatment and should only be used in combination with aspirin and caffeine 4
• Do not allow patients to increase acute medication frequency in response to treatment failure: this creates a vicious cycle of medication-overuse headache; instead transition to preventive therapy 1
• Do not use opioids as first-line therapy: they have questionable efficacy, risk of dependency, and contribute to rebound headaches 3, 4