Migraine Cocktail Components
The standard migraine cocktail for acute treatment in an adult without contraindications consists of an NSAID (ketorolac 30mg IV), an antiemetic with direct analgesic properties (metoclopramide 10mg IV or prochlorperazine 10mg IV), and for severe or refractory cases, dihydroergotamine (DHE) 1mg IV or subcutaneous sumatriptan 6mg. 1, 2
Core Components
Primary Analgesic: NSAID
- Ketorolac 30mg IV is the preferred parenteral NSAID with rapid onset of action and approximately 6 hours duration, making it ideal for severe migraine with minimal rebound headache risk 1, 2
- For oral outpatient cocktails, naproxen sodium 500-825mg or ibuprofen 400-800mg serve as first-line NSAIDs 1, 3
Antiemetic with Analgesic Properties
- Metoclopramide 10mg IV provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties, and enhances absorption of co-administered medications through prokinetic effects 1, 2
- Prochlorperazine 10mg IV is equally effective as metoclopramide for headache pain relief and has a more favorable side effect profile than chlorpromazine (21% vs 50% adverse events) 1, 2
- Both agents provide synergistic analgesia beyond simply treating nausea 1
Rescue/Severe Attack Component
- Dihydroergotamine (DHE) 1mg IV or intranasal has strong evidence for efficacy and safety as monotherapy for severe or refractory migraine attacks 1, 2
- Subcutaneous sumatriptan 6mg provides the highest efficacy among all triptan formulations, with 59% achieving complete pain relief by 2 hours and onset within 15 minutes 1, 2
Optimal Combination Strategies
Emergency Department/IV Cocktail
- First-line: Ketorolac 30mg IV + Metoclopramide 10mg IV represents the most evidence-based combination for severe migraine requiring IV treatment, providing rapid pain relief while minimizing side effects and rebound risk 1
- For inadequate response after 30-60 minutes: Add DHE 1mg IV or sumatriptan 6mg subcutaneously 2
Oral Outpatient Cocktail
- Sumatriptan 50-100mg PLUS naproxen sodium 500mg is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours 1
- This combination should be taken early in the attack while pain is still mild for maximum effectiveness 1
Critical Frequency Limitation
Limit all acute migraine medications to no more than 2 days per week (10 days per month) to prevent medication-overuse headache, which paradoxically increases headache frequency and can lead to daily headaches. 1, 2 If requiring acute treatment more than twice weekly, initiate preventive therapy immediately 1
Contraindications Requiring Alternative Approach
- Triptans and DHE are absolutely contraindicated in patients with ischemic heart disease, uncontrolled hypertension, basilar or hemiplegic migraine, or significant cardiovascular disease 1, 2, 4
- Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction 1
- Prochlorperazine has additional contraindications including CNS depression and use of adrenergic blockers, with risks of tardive dyskinesia, hypotension, and arrhythmias 1
Medications to Avoid
Never use opioids or butalbital-containing compounds for acute migraine treatment as they have questionable efficacy, lead to dependency, cause rebound headaches, and result in loss of efficacy over time. 1, 2 Opioids should only be reserved for cases where all other medications are contraindicated, sedation is not a concern, and abuse risk has been addressed 1
Alternative Components for Contraindications
For Cardiovascular Contraindications to Triptans/DHE
- Gepants (ubrogepant 50-100mg or rimegepant) have no vasoconstriction and are safe for patients with cardiovascular disease 1
- Lasmiditan 50-200mg is a 5-HT1F receptor agonist without vasoconstrictor activity, though patients cannot drive for 8 hours after administration 1