Migraine Cocktail in Urgent Care Setting
The optimal migraine cocktail for urgent care is metoclopramide 10 mg IV plus ketorolac 30 mg IV, which provides rapid pain relief through synergistic 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, 2
- Enhances absorption of co-administered medications by overcoming gastric stasis during migraine attacks 1
- Should be given even if the patient is not actively vomiting, as nausea itself is one of the most disabling migraine symptoms 1, 2
Ketorolac 30 mg IV
- Offers relatively rapid onset with approximately 6 hours of duration 1
- Carries minimal risk of rebound headache compared to opioids 1
- Dose adjustment: Use 15 mg IV for patients ≥65 years or with renal impairment 1
Alternative IV Options When First-Line is Contraindicated
Prochlorperazine 10 mg IV
- Comparable efficacy to metoclopramide for headache pain relief 1, 3
- More favorable side effect profile than chlorpromazine (21% vs 50% adverse events) 1
- Contraindications: CNS depression, concurrent use of adrenergic blockers 1
Dihydroergotamine (DHE)
- Consider for patients with contraindications to NSAIDs 1
- Has good evidence for efficacy as monotherapy 1, 2
Critical Contraindications to Screen For
Metoclopramide contraindications:
- Pheochromocytoma, seizure disorder, GI bleeding, GI obstruction 1
Ketorolac contraindications:
- Renal impairment (CrCl <30 mL/min), history of GI bleeding, active cardiovascular disease 1
Medication-Overuse Headache Prevention
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, 2, 4
- If patients require acute treatment more frequently, immediately initiate preventive therapy rather than increasing acute medication frequency 1, 2
Discharge Prescriptions
For patients without prior triptan use:
- Sumatriptan 50-100 mg PLUS naproxen sodium 500 mg for home treatment of future attacks 1
- This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
Anti-emetic prescription:
- Metoclopramide 10 mg orally or prochlorperazine 25 mg orally/suppository for patients with recurrent nausea 2
- Only 46.2% of patients with nausea receive anti-emetic prescriptions in urgent care settings, representing a significant treatment gap 5
Common Pitfalls to Avoid
- Do not use opioids (hydromorphone, meperidine) as they lead to dependency, rebound headaches, and loss of efficacy 1, 6
- Do not add diphenhydramine routinely unless specifically treating akathisia from dopamine antagonists 1
- Do not withhold antiemetics until vomiting occurs—nausea alone warrants treatment 1, 2
- Do not discharge without triptan prescription if patient has no documented prior triptan use—only 11.1% receive this in current urgent care practice 5