From the Guidelines
A common migraine cocktail used in emergency departments typically includes a combination of medications to address pain, nausea, and inflammation, such as intravenous metoclopramide (10 mg) or prochlorperazine (10 mg) for nausea, ketorolac (30 mg IV) for inflammation and pain, and diphenhydramine (25-50 mg IV) to prevent akathisia (restlessness) that can occur with the anti-nausea medications, as recommended by studies 1.
Migraine Cocktail Components
- Intravenous metoclopramide (10 mg) or prochlorperazine (10 mg) for nausea
- Ketorolac (30 mg IV) for inflammation and pain
- Diphenhydramine (25-50 mg IV) to prevent akathisia (restlessness) that can occur with the anti-nausea medications
Additional Considerations
- IV fluids for hydration, particularly if the patient has been vomiting
- Magnesium sulfate (1-2 g IV) for patients with aura or those who haven't responded to initial treatments
- Dexamethasone (10 mg IV) to help prevent headache recurrence
Patient-Specific Factors
- Medical history
- Previous medication responses
- Hospital protocols These medications work together by targeting different aspects of migraine pathophysiology - reducing inflammation, blocking pain pathways, addressing associated symptoms like nausea, and potentially interrupting the neurogenic inflammation cascade that perpetuates migraine attacks, as supported by studies 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Migraine Cocktail in the ER
- A combination of sumatriptan and metoclopramide has been shown to be effective in treating migraines in the emergency department 2.
- Metoclopramide alone has also been found to be effective in relieving migraine pain and is considered a viable alternative to sumatriptan 3, 4, 5.
- The American Headache Society recommends offering intravenous metoclopramide, prochlorperazine, and subcutaneous sumatriptan to eligible adults who present to an ED with acute migraine 4.
Comparison of Therapeutic Effects
- A study comparing the effects of magnesium sulfate and combined use of dexamethasone/metoclopramide found that magnesium sulfate was a more effective and fast-acting medication for the treatment of acute migraine headaches 6.
- Another study found that metoclopramide and sumatriptan relieved migraine headache pain comparably, with some secondary endpoints suggesting that metoclopramide may be the preferable therapy for migraines presenting to the emergency department 5.
Treatment Options
- Metoclopramide 10 mg IV is considered a first-line medication for migraine attacks in ED settings 3.
- Sumatriptan 3 mg SQ is also a recommended treatment option for acute migraine in the emergency department 2, 4.
- Magnesium sulfate may be considered as an alternative treatment option for acute migraine headaches 6.