Migraine Cocktail in Urgent Care
For an adult with typical migraine in urgent care, administer metoclopramide 10 mg IV plus ketorolac 30 mg IV as first-line therapy—this combination provides superior pain relief through synergistic analgesia while minimizing rebound headache risk. 1, 2, 3
First-Line IV Cocktail Components
Metoclopramide 10 mg IV is the cornerstone antiemetic that provides direct analgesic effects through central dopamine receptor antagonism, independent of its antiemetic properties. 1, 2 This should be administered 20–30 minutes before or concurrently with the NSAID to achieve synergistic pain relief. 2
Ketorolac 30 mg IV (or 60 mg IM for patients under 65 years) delivers rapid-onset analgesia with approximately 6 hours of duration and carries minimal risk of rebound headache compared to other acute migraine medications. 1, 2, 3 For patients ≥65 years or with renal impairment, reduce the dose to 30 mg. 2
Consider adding diphenhydramine 25-50 mg IV to metoclopramide to reduce the risk of extrapyramidal side effects, particularly akathisia and dystonic reactions. 3
Alternative IV Options When First-Line Is Contraindicated
If NSAIDs are contraindicated (renal impairment with creatinine clearance <30 mL/min, active GI bleeding, or aspirin/NSAID-induced asthma), dihydroergotamine (DHE) 0.5-1.0 mg IV has good evidence for efficacy as monotherapy. 4, 1, 2 DHE can be repeated every hour up to a maximum of 2 mg IV per day. 4
Prochlorperazine 10 mg IV is comparable in efficacy to metoclopramide and may be substituted when metoclopramide is contraindicated. 1, 2 Prochlorperazine has a more favorable side effect profile than chlorpromazine (21% vs 50% adverse event rate). 2
Critical Contraindications to Screen Before Treatment
Metoclopramide is contraindicated in patients with pheochromocytoma, seizure disorder, GI bleeding, or GI obstruction. 2
Ketorolac should not be used in patients with renal impairment (CrCl <30 mL/min), history of GI bleeding, or active cardiovascular disease. 2
DHE is contraindicated with concurrent triptan use (within 24 hours), beta blockers, uncontrolled hypertension, coronary artery disease, pregnancy, and sepsis. 4
Oral Outpatient Cocktail for Discharge
For patients being discharged or those who can tolerate oral medications, sumatriptan 50-100 mg PLUS naproxen sodium 500 mg represents the strongest evidence-based combination. 1, 2 This combination is superior to either agent alone, with 130 more patients per 1000 achieving sustained pain relief at 48 hours and 90 more patients per 1000 achieving pain relief at 2 hours compared to monotherapy. 2
Subcutaneous sumatriptan 6 mg provides the highest efficacy among all triptan formulations, with 59% achieving complete pain relief by 2 hours and onset of action within 15 minutes. 4, 2 This route is particularly useful for patients with rapid progression to peak intensity or significant nausea/vomiting. 2
Medications to Absolutely Avoid
Never prescribe opioids (hydromorphone, oxycodone, codeine) or butalbital-containing compounds for migraine treatment. 1, 2, 3 These medications have questionable efficacy, lead to dependency, cause medication-overuse headache, and worsen long-term outcomes regardless of pain severity. 1, 2
Critical Frequency Limitation to Prevent Medication-Overuse Headache
Strictly 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, 3 This non-negotiable limit applies to NSAIDs, triptans, metoclopramide, and all other acute agents. 1, 2
If the patient requires acute treatment more than twice weekly, initiate preventive therapy immediately rather than increasing the frequency of acute medications. 1, 2
Special Considerations for Severe Nausea/Vomiting
When significant nausea or vomiting is present early in the attack, use non-oral routes exclusively (IV, subcutaneous, or intranasal formulations). 1, 3 Oral medications are poorly absorbed during migraine attacks due to gastric stasis. 2
Intranasal sumatriptan 5-20 mg or subcutaneous sumatriptan 6 mg are preferred alternatives when IV access is not available. 4, 2
Red Flags Requiring Urgent Evaluation Before Treatment
Before administering symptomatic treatment, rule out secondary causes by evaluating for: focal neurological deficits, headache that wakes the patient from sleep, progressive worsening pattern, fever with headache (suggesting meningitis), thunderclap onset, or new-onset headache after age 50. 2, 3 If any red flags are present, perform urgent neuroimaging before initiating treatment. 3
Transition to Preventive Therapy
Initiate discussion about preventive therapy if the patient experiences ≥2 migraine attacks per month causing disability lasting ≥3 days, or if acute medications are needed more than twice weekly. 1, 3 Evidence supports topiramate, propranolol, metoprolol, amitriptyline, or CGRP monoclonal antibodies for prevention. 3
Common Pitfalls to Avoid
Do not allow patients to increase the frequency of acute medication use in response to treatment failure—this creates a vicious cycle of medication-overuse headache. 2 Instead, transition to preventive therapy while optimizing the acute treatment strategy. 2
Do not restrict metoclopramide only to patients who are actively vomiting—nausea itself is one of the most disabling symptoms and warrants treatment even in the absence of vomiting. 2