What to Know About a Migraine Cocktail in the ER

As you may be aware, people with severe migraine pain sometimes pay a visit to the Emergency Room of their local hospital. In fact, over 1.2 million people a year visit an ER for treatment of migraine pain. 

Perhaps you’ve even been one of them! If so, hospital staff may have treated your severe migraine with what’s known colloquially as a migraine cocktail. In essence, the ER is treating you with a combination of medications and treatments tailored to effectively treat a severe migraine attack. 

More complex, treatment-resistant migraines — those that don't respond to single treatments — may call for such a blend of treatments to bring relief from severe migraine pain. Certain combinations of migraine treatments have been well studied and may be suitable to help with treatment-resistant migraines. 

On the other hand, because investigation is ongoing regarding interactions and subsequent side effects between various medications, some medical professionals caution against use of certain “cocktail” treatments within hospitals. 

And of course, to avoid potentially adverse drug reactions, it’s always imperative that individuals with severe migraine consult a physician before attempting to combine any medications or treatments on their own at home, even medications that they may typically use separately. Because every person responds differently to drugs and dosage levels, interactions between drugs may cause serious side effects or magnify the typical clinical response. This could lead to in-hospital treatment.

‍What’s in a Migraine Cocktail?

A migraine cocktail typically refers to a combination of drugs administered intravenously in the ER to treat a particularly severe migraine; that is, one that has lasted over 72 hours (status migrainosus) or hasn’t responded to prescription or over-the-counter (OTC) medications. 

‍Over 20 medications are currently in common usage to treat migraine in the US, some of them approved for use in combination with others in the ER. 

‍Intravenous (IV) Treatment for Severe Migraine

Medications that may be used in some combination in a migraine cocktail include: 

• Dopamine Antagonists (Neuroleptics): The American Headache Society recommends drugs such as IV Metoclopramide and Prochlorperazine as a class 'B' treatment ('should offer') when the ER is treating nausea and vomiting from acute migraine. Some rare side effects include agitation, dizziness, and hypotension; these may be reduced by administration of diphenhydramine in the ER.
• Serotonin Antagonists (Triptans): IV Sumatriptan (6mg) is a standard ER treatment for people with acute migraine. It is thought to bind to the serotonin receptors which cause constriction of blood vessels in the head and neck. Side effects can include flushing, weakness, drowsiness, dizziness, and a feeling of warmth; most resolve after 30 minutes. 
• Nonsteroidal Anti-Inflammatories (NSAIDs) (Ketorolac): Ketorolac is similar to ibuprofen and may be administered in the ER via IV for pain relief. 
• Anti-Epileptics (Sodium Valproate):  Limited evidence suggests that IV sodium valproate may be an effective treatment for acute migraine — in a recent study, individuals experienced some pain relief after two hours. Adverse effects of valproate may include nausea, vomiting, and tremor.
• Corticosteroids (Dexamethasone): Dexamethasone is similar to a natural hormone produced by your adrenal glands. It may be used in the ER in conjunction with other treatments to reduce headache recurrence 24-72 hours after initial abortive treatment. 

‍Migraine Cocktails at Home? Not Advisable

The simple advice is: don’t mix medications on your own.

Instructions for combining various over-the-counter (OTC) medications to create a migraine cocktail at home often pop up on the Internet. However, there is a lot of misinformation about which drugs should be taken together, and medical professionals advise that you do not attempt at-home combinations of medications on your own, due to potential adverse drug reactions.  

When managing your migraine treatment at home, it’s critical that you inform your physician about any drug(s) — OTC or prescription — that you may want to try in combination, so your doctor can help you avert any bad interactions. 

Some combinations that your physician may potentially OK for your use: 

• Acetaminophen-Aspirin-Caffeine. Acetaminophen, or Tylenol, is the standard first treatment to be taken for migraine pain. It is safe in conjunction with NSAIDs such as aspirin. In this study, the acetaminophen/aspirin/caffeine cocktail was shown to be more effective in reducing migraine symptoms when taken in combination rather than alone. However, this combination raises a concern that it may potentially result in medication overuse headache. 
• Triptans and NSAIDs. Some evidence suggests that combining a triptan with an NSAID, such as naproxen sodium, provides effective relief of migraine. 
• NSAIDs and Antiemetics. Antiemetics such as metoclopramide may be prescribed in combination with NSAIDs to help decrease nausea and vomiting. 

These well-researched combinations of medications have been declared unsafe if taken together: 

• Triptans and Ergot Alkaloids. Ergot alkaloids, such as dihydroergotamine (MIgranal), are a class of drugs that treat migraine headaches. Because both work by constricting arteries, they should not be combined. 
• Triptans and SSRIs. Many patients with migraine also have depression or anxiety, so it’s common for migraine patients to be using SSRIs, a class of antidepressants such as Citalopram (Celexa) and Fluoxetine (Prozac). However, because both drugs affect serotonin, combining the two may cause serotonin syndrome, a serious drug reaction with symptoms ranging from shivering and muscle rigidity to fever and seizures. In severe cases, it may even cause death.

‍When to Seek Help for Migraine

Everyone’s experience with migraine is unique to them. Mable’s worldwide team of leading migraine experts focuses on bringing you positive change, through a DNA-guided treatment program that gives you a clearer picture of why and how your migraines occur, based on your genetics and the latest evidence and clinical practice. 

Our headache specialists help tailor your migraine treatment plan specifically to you, then work with you to help reduce the frequency and severity of your migraine and return you to the lifestyle you love. 

Mable could be the right approach for you. Take our 2-minute quiz and see.