What Is A Migraine Cocktail?

Migraines are highly debilitating and more than just a headache, causing symptoms ranging from nausea to temporarily losing your vision. Properly managing them can be a challenge, and if you do get a migraine, you want to alleviate it quickly.

One possibility for relief is a so-called migraine cocktail.

What is a migraine cocktail?

A migraine cocktail is a combination therapy containing various drugs to try and provide quick relief. It’s an acute headache management technique doctors use in emergency departments. People with migraines can end up in the ER when they get a particularly bad episode.

You may not know you have a migraine or headache disorder until a severe attack happens. This is most likely with children or people who have had a recent life event that triggered their migraine attack.

While “migraine cocktail” is a common term, some medical professionals and patients don’t like the alcoholic beverage connotations. 

What do migraine cocktails contain?

The typical approach will be abortive therapy (treatment to stop the migraine once it starts) with different medications. The exact contents of a migraine cocktail vary by provider and your needs, but they typically consist of the following:

Steroids

The usual steroid for migraine cocktails is dexamethasone. While dexamethasone does not treat headaches, it decreases the risk of recurrence in the short term. Some providers prefer to avoid steroids because of the chance of migraines reappearing and doctors overusing steroids, increasing the risk of side effects.

Triptans

Triptans are the typical first-line agents for treating acute migraine episodes. They are serotonin 1b/1d agonists specifically developed for migraines. They inhibit the release of vasoactive peptides (proteins that dilate vessels), contracting blood vessels and blocking pain pathways in your brain stem. 

Your doctor may use one of the various medications depending on the severity of your headache and your age. For example, only Zolmitriptan is FDA-approved in children 12 years and over.

Although they’re not a first-line treatment, triptans are suitable during pregnancy.

Ergot alkaloids

Ergot alkaloids are isolated from the ergot fungus, which is psychoactive and toxic in its whole state. Ergotamine and dihydroergotamine constrict blood vessels and reduce neurogenic inflammation. However, these drugs can also cause or worsen nausea.

Antiemetics

Migraines can cause severe nausea. Antiemetics treat vomiting and nausea, and they can also limit the perception of pain, easing both symptoms at once. These medications can make you drowsy.

Doctors may add an antiemetic to speed up your recovery. Nausea and vomiting can cause dehydration, which worsens migraine symptoms in general. Antiemetics can also counteract the tendency of ergot alkaloids to cause nausea.

CGRP antagonists

Elevated levels of calcitonin gene-related peptides (CGRP) are one migraine mechanism. CGRP antagonists bring these levels back down and can ease symptoms. They also prevent attacks.

Lasmiditan

Lasmiditan is a new drug that blocks serotonin receptor sites that transmit headache pain. It is most useful as soon as a migraine starts, but it’s also suitable for acute management.

Magnesium

Magnesium deficiency can contribute to migraines, and giving magnesium helps manage symptoms by 

NSAIDs

Finally, a migraine cocktail typically contains an NSAID, most often ketorolac.

Emergency departments might also administer fluids, especially if you have been vomiting. Again, the precise ingredients and combination vary, but doctors generally don’t use opioids when treating acute migraine. If the treatment works, you should find out what your doctor gave you and note it in case you need it in the future. 

When would someone receive a migraine cocktail?

Migraine cocktails are generally only given if you present at the emergency department with a severe attack that doesn’t respond to typical medications (or OTC medicine). If you have status migrainosus, an attack that lasts over 72 hours, your doctor will use a migraine cocktail.

Migraine cocktails reduce pain scores and prevent hospital admission. Additionally, the combination gives solid clues about what medications work for you.

How safe is this treatment?

Migraine cocktails administered in the emergency department are generally safe, although there are often side effects, and there may be risks if care is not taken.

Potential side effects

Specific side effects depend on the drugs::

• Ergot alkaloids: Nausea, which can worsen pre-existing nausea

• Corticosteroids: Adrenal suppression, osteonecrosis, and elevated serum glucose levels, especially if you have taken steroids recently

• NSAIDs: People who have peptic ulcers or are at high risk should not take NSAIDs

• Antiemetics: Sedation and postural hypotension (low blood pressure when you stand up)

As side effects depend on the specific drugs your doctor uses, ask what to watch out for. 

Can I get an over-the-counter migraine cocktail?

Yes. There are over-the-counter migraine cocktails available at a pharmacy. Typically these cocktails contain three ingredients: Acetaminophen (Paracetamol), aspirin, and caffeine.

Excedrin Migraine is a migraine cocktail, so you may already be taking one without realizing it. Speak to your doctor if you need this kind of medication frequently. It’s a sign that you’re potentially not managing your migraines well. Your doctor may be able to prescribe better options, such as medications that prevent attacks from occurring in the first place.

Can you make a migraine cocktail at home?

In theory, you could make a migraine cocktail by buying the three ingredients in over-the-counter migraine cocktails and combining them. Talk to your doctor or a pharmacist before doing this. They can help you get the dosage right for your specific case. Also, tell your doctor how you are controlling your migraines.

Alternative treatments

Not all doctors use migraine cocktails, and others may try something else first. Monotherapy with an appropriate drug is another option, depending on your symptoms.

Fluids are an important part of treating migraines, especially if you’re throwing up. This can be challenging at home if you still have nausea, and dehydration worsens migraine.

Alternative and complementary treatments for migraine include:

• Mindfulness and meditation

• Acupuncture

• Botulinum toxin, which appears to relieve headaches and associated symptoms, including photophobia and phonophobia (intolerance of light or sound)

• Massage therapy

• Yoga

• Exercise

• Hypnosis

• Desensitizing triggers

• Transcranial magnetic stimulation (TMS)

• Transcutaneous supraorbital nerve stimulation (tSNS)

• Coenzyme Q10, which may prevent migraine episodes, although more studies are needed

• Riboflavin (vitamin B2), which may support the contribution of mitochondrial dysfunction leading to migraine, although further studies are required to determine the optimum dose and the patient population most likely to benefit

The lowdown

If you’re in the ER with a severe migraine, your doctor may give you a migraine cocktail to get your headache under control quickly. These treatments are generally safe, but they can have various side effects.

You can treat milder migraines with over-the-counter migraine cocktails at home. You can potentially make your own, although you should check with your doctor first.