What is a Migraine Cocktail?

Unfortunately, there is no cure for migraine, a headache disorder that affects an estimated 44.5 million adults in the United States.

But there are several medications that can treat symptoms during an attack, as well as prevent attacks from occurring.

A specific combination of medications, sometimes referred to as a migraine cocktail, can be used to treat severe symptoms in an emergency department, outpatient infusion center, or even at home. 

In this article, I’ll explain what a migraine cocktail is, how it’s administered, and which combination of medications it may contain.

I’ll also cover when to reach out to your healthcare provider if you’re experiencing symptoms.

What is a Migraine Cocktail?

A migraine cocktail is a combination of medications and treatments used to treat severe migraine symptoms.

The exact combination can vary for every patient. 

Medications that May Be in a Migraine Cocktail

Migraine is a common reason for emergency department visits.

When someone comes to the emergency department (ER) for migraine treatment, they have already tried to treat their symptoms at home, but have failed to find relief. In fact, most people who visit the ER for a migraine attack have already been experiencing symptoms for more than 72 hours.

When treated in an ER or outpatient center, a migraine cocktail may contain a combination of the following treatments. 

Triptans

Triptans are FDA-approved prescription medications that are an effective first-line treatment for moderate to severe migraine.

They can have an anti-inflammatory effect, which is believed to help narrow blood vessels in the brain, reducing the pain associated with a migraine headache.

Types of triptan medications include: almotriptan (Axert), eletriptan (Relpax), frovatriptan (Frova), naratriptan (Amerge), rizatriptan (Maxalt), sumatriptan (Imitrex), and zolmitriptan (Zomig).

Evidence suggests that triptans are most effective when taken early during a migraine attack. 

Antiemetics

Antiemetics are dopamine antagonist medicines that are usually administered via injection.

Antiemetics can be especially helpful at treating nausea associated with a migraine headache, but they can cause adverse reactions, like sedation.

Examples of antiemetic medications include chlorpromazine, droperidol, metoclopramide, and prochlorperazine.

Ergot alkaloids

Ergot alkaloids provide a similar benefit to triptans, however a common side effect is nausea.

Dihydroergotamine (DHE) is an example that is better tolerated than most other ergot alkaloids. 

NSAIDs

Nonsteroidal anti-inflammatory drugs (NSAIDs) are considered a first-line treatment for mild to moderate migraine headaches.

Over-the-counter (OTC) NSAIDs that can work include aspirin, diclofenac, ibuprofen (Advil), and naproxen (Aleve).  

IV steroids

Certain steroids can relieve pain and reduce inflammation.

IV fluids

Dehydration is a common trigger of migraine.

Certain symptoms of migraine, including nausea and vomiting, can further exacerbate dehydration.

For these reasons, IV fluids are sometimes administered as part of a migraine cocktail. 

IV magnesium

Magnesium sulfate may be most effective for people experiencing severe symptoms of migraine with aura.

IV valproic acid

In severe cases, valproic acid (a seizure medication) may be used to help treat symptoms.

Side Effects of a Migraine Cocktail

Some of the most common side effects experienced with a migraine cocktail include:

• Fatigue or sedation
• Nausea
• Upset stomach
• Aches and pains

Over-the-Counter (OTC) Migraine Cocktail

Over-the-counter (OTC) medications are an important component of migraine therapy, and are often considered a first-line treatment.

A combination of certain OTC medications can also be tried at home when experiencing symptoms.

A combination of aspirin, acetaminophen, and caffeine is considered particularly safe and effective for migraine headaches. 

Aspirin

250 mg of aspirin is recommended as part of this cocktail to help reduce pain and inflammation.

Acetaminophen

250 mg of acetaminophen is also recommended to treat symptoms of a migraine headache.

Caffeine

65 mg of caffeine will provide antioxidant and anti-inflammatory properties while also reducing blood flow in the brain.

It may also make acetaminophen absorb faster and stay in your body for longer.

Is an OTC Migraine Cocktail Safe?

The above combination of aspirin, acetaminophen, and caffeine is considered a safe and effective treatment by the FDA and American Headache Society.

It can also be used to treat tension and cluster headaches.

This cocktail may not be right for everyone, including:

• Children 12 years and younger
• Those taking other medications containing acetaminophen or NSAIDs
• Those allergic to any of the three medications
• Those with kidney, liver, or heart disease
• People who are pregnant or breastfeeding

If you’re unsure whether or not an OTC migraine cocktail is safe for you, contact your healthcare provider for more information.

Other Ways to Relieve Migraine Symptoms

Though a migraine cocktail may help to treat symptoms during an acute attack, there are other treatments and methods that can help.

Keep in mind that not all of these options will work for you.

It may take some trial and error to find the right strategies to mitigate your symptoms.

Medications

In addition to the options mentioned earlier, there are other medications that can help to treat and prevent migraine symptoms, including:

• Opioids: Butorphanol, codeine, tramadol, and meperidine (Demerol) have moderate evidence of effectiveness in treating migraine, but they aren’t prescribed as often given the high potential for abuse and dependence.

• Ditans: Ditans work to block the processes that lead to the development of severe migraine headaches. The first medication in this group, called lasmiditan (Reyvow), has been approved by the FDA for short-term treatment in people with and without migraine aura.

• Erenumab (Aimovig): This medication has been approved to help prevent migraine in adults.

Therapies

Studies show that several nonpharmacological therapies may be effective for those suffering from migraine:

• Massage: Some studies show that massage may help reduce migraine frequency.

• Acupuncture: Research shows that acupuncture can help to reduce chronic pain by increasing circulation, decreasing inflammation, boosting the body’s release of endorphins (also known as the body’s natural painkillers), and increasing adenosine release, which can reduce the severity of chronic pain through adenosine A1 receptors. Acupuncture may also help to reduce sympathetic nerve activity in the treatment of migraine.

Lifestyle changes

There are many factors that can trigger an attack of migraine headache, including stress, anxiety, hormonal changes, and more.

Identifying these triggers and avoiding them with lifestyle changes may help to treat and prevent migraine headaches.

Several lifestyle changes that may be helpful include:

• Drink more water: Staying hydrated throughout the day may help to prevent migraine attacks.

• Establish good sleep hygiene: Going to bed around the same time every night, limiting exposure to blue light, and waking up at the same time every day are three core strategies to helping your body get regular, quality sleep—which can help reduce the frequency of migraine attacks.

• Manage stress: Stress reduction strategies, including mindfulness and yoga, may help improve disability, quality of life, self-efficacy, pain catastrophizing, and depression, overall improving total migraine burden. 

• Limit chewing and/or teeth grinding: Though more research is needed to determine whether teeth grinding causes migraine, avoiding gum-chewing or wearing a nightguard may help improve the frequency or severity of migraine symptoms.

If you’re unsure whether or not certain triggers impact your migraine headaches, keep a diary of when you experience an attack and which trigger may or may not have been involved. 

When to See a Doctor for Migraine

Severe migraine headaches can cause debilitating symptoms that have a negative impact on your quality of life.

But that doesn’t mean that treatment, prevention, and relief aren’t possible.

Contact your healthcare provider or a neurologist to discuss which treatment options may work best for you.

In the meantime, consider keeping a migraine diary when you experience symptoms to keep track of which factors, if any, may be triggering them.

Not all severe headaches are a sign of migraine. In rare but serious cases, a severe headache may be a sign of something else.

If you experience any of the below symptoms, seek immediate medical attention: 

• Fever
• Nausea
• Shortness of breath
• Weakness in the body
• Confusion
• Double vision
• Stiff neck
• The “worst” headache of your life
• A headache prompted by a head injury
• A severe and sudden headache

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