What Should You Know About Migraine Cocktails?

While a cocktail may be the very least appealing thing to you in the throes of a migraine attack, a "migraine cocktail" could be the very thing that helps break it. Learn what this rescue therapy comprises and when it might be time to visit the emergency room (ER) to get it.

When Should I Go to the ER for a Migraine Attack?

Before we get into the details of migraine cocktails, let’s talk about the most common reason you’d want one: You have severe migraine symptoms. What kinds of severe migraine symptoms require emergency care?

The first is a migraine attack that begins abruptly or has symptoms far different than usual. If there are associated neurological symptoms that are different from those that have been present in the past; if there's fever; or if there's an extremely abrupt onset of headache (reaching peak severity within one minute) — these could be signs of an emergent secondary headache, which is a headache caused by something other than preexisting migraine. Some of those causes can be serious, so if this is what’s happening, get someone to take you to the nearest ER or call for help.

The second is a severe migraine attack that hasn’t responded to your usual treatments. If your regular acute migraine treatments won’t touch the symptoms, or if nausea/vomiting makes it impossible for you to keep medication in your system long enough to work or you’re risking dehydration, visit the urgent care center or ER for acute treatments delivered intravenously (IV) or by injection. An attack lasting 72 hours or more without a break (except for sleeping, if you can sleep), or status migrainosus, also calls for an urgent care or ER visit.

What's in a Migraine Cocktail?

“Migraine cocktail” is the nickname for a combination of medications, often paired with IV fluids, that is given intravenously or intramuscularly in an urgent care setting or emergency department. This is also known as an IV/IM rescue therapy.

Although the term “migraine cocktail” is commonly used by healthcare providers, headache specialists prefer terminology such as “rescue therapy” because it does not include the associations that come with the word cocktail. You might hear either term in urgent care or emergency care departments, but they refer to the same approach.

A typical migraine cocktail or rescue approach usually includes anti-inflammatory medications/analgesics (like ketorolac (Toradol)), an antinausea agent (such as prochlorperazine (Compro) or metoclopramide (Reglan)), and, in some cases, antiseizure medications (like valproic acid (Depakote.)) Some healthcare providers will include magnesium as part of the cocktail or rescue approach.

IV fluids may be useful as part of a rescue plan, especially if you’re dehydrated from vomiting or poor intake of liquids.

It is generally recommended to use migraine-specific acute therapies — like a triptan, gepant, or lasmiditan — as a first-line approach before going to the less-migraine-specific components of a migraine cocktail or rescue therapy. Often people have tried acute migraine medications before they go to urgent care or the emergency department (ED) — but not always.

What Medications Does the ER Give You for a Migraine Attack?

That varies quite a bit from one institution to another. Healthcare providers in the ER give you symptomatic medications, typically to treat nausea and pain. They may give the medicines in combination, depending on what symptoms you present with. In some places, they will give you migraine-specific therapies if you haven't tried one before going to the ER.[1]Migraine Again Verified Source

Gelfand AA et al. A Neurologist's Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist. April 2012.

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Healthcare providers typically want to encourage you to develop an understanding of what is effective for you so that if you have to utilize an emergency or urgent care setting, you can communicate to the providers there what has worked in the past.

Different facilities and providers may begin migraine cocktail treatment with their own preferred variations on the basic formula. An additional ingredient, like an extra antiemetic or an antihistamine (like diphenhydramine (Benadryl)), or a slightly different combination of standard medications, may provide better relief than another combination. If you notice that a particular visit was more successful than others, make sure you get the list of exactly which medications you received in your after-care paperwork.

Questions and Answers About the Migraine Cocktail

What is a "migraine cocktail?"

When should someone seek emergency care for a migraine?

Can a migraine cocktail be administered at an urgent care center?

Is it possible to take a migraine cocktail at home?

What are some ways to relieve migraine symptoms at home?

Does the ER Doctor or My Healthcare Provider Prescribe the IV/IM Rescue Plan?

While you're in the ED, it is important to understand that you are the responsibility of the healthcare providers there and they will assess you and give you the care that they think is appropriate. It is also important, however, to provide information — either on your own or from your primary care provider or a headache specialist — that indicates what therapy you've responded to in the past or what therapy you think is appropriate.[2]Migraine Again Verified Source

Orr SL et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache: The Journal of Head and Face Pain. June 2016.

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One thing to be aware of is that providers in an emergency setting are always going to be wary if you request opioids. Because migraine may not have overt symptoms or signs, there may be a suspicion that you are embellishing symptoms or using migraine as a reason to obtain opioids. This is one of the sticky issues surrounding the topic of opioids in the ED setting.

This can be a difficult problem to navigate, especially if you visit ERs frequently or do not respond to the most common cocktail combinations. The American Headache Society does not recommend opioids for the treatment of migraine, but they are sometimes administered in the ER. This is considered suboptimal care for treating migraine disease, as opioids can sensitize the brain, worsen the pain, and lead to medication overuse headache.[3]Migraine Again Verified Source

Opioids and Migraine. American Headache Society.

View Source [4]Migraine Again Verified Source

Minen MT et al. Evaluation and Treatment of Migraine in the Emergency Department: A Review. Headache: The Journal of Head and Face Pain. July 16, 2014.

View Source And unfortunately, the patients this affects most are those in marginalized and underserved groups. According to data from the The Headache and Migraine Policy Forum, Black people are 46 percent more likely to go to the ER for migraine than their white counterparts, because they are more likely to be denied coverage for treatments by their insurance companies. And, on top of that, they often feel dismissed or are seen as drug-seekers when they go to the ER for care.[5]Migraine Again Verified Source

Buse D et al. The Effect of Barriers to Treatment Access on Emergency Department Usage by Race/Ethnicity in the United States: A Claims Data Analysis.

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If you find yourself in a situation where you’re relying on emergency care, you might try the approach Migraine Again contributor Jaime Sanders uses. After one ER visit where a change to the migraine cocktail produced much better results than previous attempts, she worked with her headache specialist to create an emergency migraine treatment protocol:

… I immediately faxed my doctor the summary of my visit, detailing what I was given. I asked that he type up a migraine treatment protocol with those specific medications and doses for whenever I need to go to the ER or urgent care again. (As someone with chronic migraine, I know this is likely.)

… Now that I have my treatment protocols, I am less likely to be questioned or treated inadequately. I keep a binder containing these protocols, plus a list of medications I’m currently taking, allergies, past visit summaries, and upcoming appointments.

This binder goes with me every time I go to my local urgent care or ER. I hand the doctor my protocol and, 9 times out of 10, I receive what is on that sheet of paper.

Can You Get a Migraine Cocktail at an Urgent Care Center?

You may be able to get an effective migraine cocktail at your local urgent care center. Urgent care centers are often far less busy and noisy than EDs in hospitals, a big plus when you’re sensitive to light and sound stimulation during a severe migraine attack. They can administer medications intravenously, just like in the ER. Treatment at an urgent care center often costs less than ER treatment, something your wallet and your insurer will like.

There are differences between urgent care centers and ERs, however, that you should understand. EDs in hospitals have a legal duty to provide a certain level of treatment to patients; urgent care centers do not. Your local urgent care center may not take your health insurance or may require payment before treatment. An urgent care migraine cocktail will likely use the same basic ingredients as a migraine cocktail in the ER, but if you require stronger or atypical medications to treat severe migraine symptoms, you may not be able to get them in an urgent care setting.

Can You Take a Migraine Cocktail at Home?

If you have been given a combination of medications in an ER or urgent care setting in the past that you know has worked well for you, your doctor may prescribe a similar combination of rescue medications as a backup for you to take at home. This can be a good option to avoid an ER visit if/when your regular migraine abortive (e.g., triptan, ditan, gepant, ergotamine) doesn’t work.[6]Migraine Again Verified Source

Migraine Cocktails: What They Are and Why They Are Misunderstood. American Migraine Foundation. February 10, 2022.

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Everyone’s at-home rescue plan looks different. Prescription NSAIDs like ketorolac (Toradol) can be prescribed for at-home usage and sometimes steroid tapers can be helpful to break a bad cycle. Also, anti-nausea medications can be prescribed in pill form or, if vomiting up medication is a problem, by rectal suppositories.

One study published in Headache showed that a combination of acetaminophen (Tylenol), acetylsalicylic acid (aspirin), and caffeine had significantly superior efficacy and speed of onset than ibuprofen (Advil) alone. The typical at-home combination includes the following: [7]Migraine Again Verified Source

Goldstein J et al. Acetaminophen, Aspirin, and Caffeine in Combination Versus Ibuprofen for Acute Migraine: Results From a Multicenter, Double-Blind, Randomized, Parallel-Group, Single-Dose, Placebo-Controlled Study. Headache: The Journal of Head and Face Pain. March 2006.

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• Acetaminophen: 250 milligrams (mg)
• Aspirin: 250 mg
• Caffeine: 65 mg

Not coincidentally, these are the same active ingredients in Excedrin Migraine. This combination can be effective; however, it is not to be used more than 10 days per month; otherwise, you run the risk of medication overuse headache.

Another more recent study on the real-world effectiveness of migraine abortive medication classes found that triptans, ergotamines, and NSAIDs (other than ibuprofen) were more effective at stopping migraine attacks than over-the-counter combination analgesics (like Excedrin Migraine.) So if your triptan didn’t help, it’s possible your attack is already at the point where it needs something stronger than Excedrin.

However, responsiveness to medication differs; talk with your doctor about formulating your own at-home migraine cocktail that might help you avoid a trip to the ER.[8]Migraine Again Verified Source

Chiang CC et al. Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users' Self-Reported Records From a Smartphone Application. Neurology. December 12, 2023.

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Other Ways to Relieve Symptoms

Knowing how a migraine cocktail can treat a severe migraine attack is helpful, but it’s better if you can avoid needing emergency treatment in the first place. If you have an attack that appears to be getting worse or your migraine symptoms aren’t responding to your usual acute migraine treatment, here are some things for you to try:

• A number of home remedies may be more effective than you expect. A variety of ways to apply ice (such as wraps and caps) or heat can reduce pain, loosen tight muscles, and bring the severity of symptoms down a few notches. Combining natural remedies with your rescue medications can have a synergistic effect. You might keep an attack from escalating if you can retreat to a dark, quiet place to rest. Many people find essential oils soothing.
• Techniques from yoga or physical therapy may help you keep an attack from getting worse. You can use many of these techniques at home once you know how. They usually take little or no expensive equipment and can be adapted to your capability.
• If your attacks are severe enough to require frequent ER visits, consider trying infusion therapy. Healthcare providers can give you a series of daily infusions of medications like dihydroergotamine (DHE) to break a particularly bad cycle of severe attacks. Infusion therapy is most often done on an in-patient basis, but there are out-patient infusion centers. Insurance often covers the cost of infusion therapy, especially if you use an in-network provider. If this option sounds good, talk to your healthcare team about the prior authorizations and in-network options.

Final Thoughts and Advice on Going to the ER for Migraine

It’s important to understand your past experiences with migraine in the ER and know what classes of medications have helped you or haven't. Then, honestly, be aware of the fact that, for many people with migraine, the ED experience is challenging and difficult. Try to develop an effective acute treatment strategy that you can administer yourself and avoid going to the ED as much as possible.[9]Migraine Again Verified Source

Charles A. Migraine. The New England Journal of Medicine. August 10, 2017.

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Consider working with your headache specialist to create an emergency migraine protocol to bring with you to emergency care providers or keep on file at your local urgent care/EDs. An emergency migraine protocol from your regular provider, using their letterhead or sent by electronic transmission, may help you avoid the worst impacts of migraine stigma and get the migraine cocktail or other treatment that works best for you.

Based on an interview with Andrew Charles, MD, and edited by Migraine Again staff.

Editorial Sources and Fact Checking

Migraine Again follows strict sourcing guidelines to ensure the accuracy of its content, outlined in our editorial policy. We use only trustworthy sources, including peer-reviewed studies, board-certified medical experts, patients with lived experience, and information from top institutions.

Sources

• Gelfand AA et al. A Neurologist's Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist. April 2012.

• Orr SL et al. Management of Adults With Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache: The Journal of Head and Face Pain. June 2016.

• Opioids and Migraine. American Headache Society.

• Minen MT et al. Evaluation and Treatment of Migraine in the Emergency Department: A Review. Headache: The Journal of Head and Face Pain. July 16, 2014.

• Buse D et al. The Effect of Barriers to Treatment Access on Emergency Department Usage by Race/Ethnicity in the United States: A Claims Data Analysis.

• Migraine Cocktails: What They Are and Why They Are Misunderstood. American Migraine Foundation. February 10, 2022.

• Goldstein J et al. Acetaminophen, Aspirin, and Caffeine in Combination Versus Ibuprofen for Acute Migraine: Results From a Multicenter, Double-Blind, Randomized, Parallel-Group, Single-Dose, Placebo-Controlled Study. Headache: The Journal of Head and Face Pain. March 2006.

• Chiang CC et al. Simultaneous Comparisons of 25 Acute Migraine Medications Based on 10 Million Users' Self-Reported Records From a Smartphone Application. Neurology. December 12, 2023.

• Charles A. Migraine. The New England Journal of Medicine. August 10, 2017.

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