Migraine Cocktails: What They Are and Why They Are Misunderstood

A treatment commonly called a “migraine cocktail” can offer relief for severe migraine attacks. Find out what it is, when it’s used and what it treats.

At least 39 million Americans live with migraine, a debilitating neurological disease. Though symptoms can vary, migraine usually involves moderate to severe head pain that can feel like throbbing, pulsating or pounding. It can also cause nausea, vomiting and sensitivity to light, noise and smells. When a person has a migraine attack, they may have to miss school, work or other activities.

There are many types of migraine and headache disorders. Common treatments include acute treatments (taken when symptoms of an attack begin) preventive medication (taken on an ongoing basis to stop attacks from happening) or a combination of treatments called a “migraine cocktail.” To learn more, we spoke to Dr. Jennifer Robblee, a neurologist and an assistant professor in the Department of Neurology at Barrow Neurological Institute in Phoenix, Arizona.

In a survey of over 1,000 American Migraine Foundation community members, 39.85% were comfortable with the term “migraine cocktail,” while 9.87% found it stigmatizing and 7.28% found it demeaning. Respondents could pick more than one answer choice. A common critique of the term is that it might make someone think of an alcoholic beverage. This adds to the stigma people living with migraine sometimes face in the ER. Interestingly, 10.54% of responses indicated the term was confusing. This is most likely because it’s unclear which specific medications are part of it. Dr. Robblee is not a fan of the term and encourages patients and providers to keep track of the exact medications they’ve tried and make note of side effects and effectiveness.

Combinations of medications and treatments are still important for those with severe migraine attacks. Dr. Robblee explains when someone would go to the hospital for migraine treatment and how these treatments can help.

Going to the ER for a Migraine Attack

You may need treatment in the ER if your typical at-home treatment medications are not working or you experience a prolonged migraine attack lasting three or more days. In those cases, a person will often go to an urgent care or get other treatments in the ER to stop their migraine symptoms.

People may also go to the hospital for treatment if it’s their first time experiencing migraine symptoms or the first time they are having a migraine with aura. “Migraine aura can actually be quite scary. It can often look almost stroke-like, and sometimes, especially in retrospect, it’s hard to actually differentiate it from a stroke or a transient ischemic attack, which is like a mini temporary stroke,” says Dr. Robblee.

Depending on your symptoms and how long they last, doctors at the hospital will treat the attack as migraine or do testing to rule out other conditions that have similar symptoms. “Just because you come to the emergency room does not mean that you need some neuroimaging [scans],” says Dr. Robblee. “We’re looking for what we like to call red flags.”

Download our free patient guides for more information about when to go to the ER for migraine, or what to expect when you’re there.

What Is a Migraine Cocktail?

Combinations of medications and treatments informally referred to as a “migraine cocktail” can occur at home, in an outpatient infusion center, an emergency department or when someone is admitted to hospital for treatment of migraine. If you go to the emergency department with a migraine attack, you may receive this combination through an IV.

The exact combination could be different for every patient but the treatment often includes non-steroidal anti-inflammatory drugs (NSAIDs) such as ketorolac. A person may also receive magnesium, certain medications to reduce nausea or vomiting, diphenhydramine (Benadryl®), dihydroergotamine or fluids to help them with their hydration. If you’re admitted to the hospital for treatment, you may receive multiple doses or a continuous infusion over several days. If this treatment works for you, be sure to get a record of what you received. This way, ER doctors will know what to do in case you require similar treatment in the future.

When Would Someone Receive a Migraine Cocktail?

This combination of medications is given to treat a severe migraine attack that isn’t responding to a person’s typical medications or OTC medicine or an attack that lasts over 72 hours (also known as status migrainosus). “When your migraine attack has gone on longer than that, then that’s when we’re starting to be a bit more aggressive to see if we can get it to stop,” says Dr. Robblee.

How long this solution offers relief can vary from person to person. Usually, once a combination works for someone, Dr. Robblee finds that they will have consistent relief with future attacks. Still, that response can evolve and change over time. “The goal is to get the attack gone and get you back to your baseline. So if you’re someone who’s usually headache-free, it gets you headache-free,” she says.

Who Administers a Migraine Cocktail?

During a hospital visit, a doctor, nurse practitioner or physician assistant will check in with you. But a nurse is often the person who administers the medications. The nurse will start the IV, check vitals and see how you respond to the medication.

If you frequently have debilitating migraine attacks, your doctor may prescribe a backup treatment to take at home. This backup treatment is often a combination of medications you’ve received and had a good response to in the past. Your doctor may also set up a way for you to schedule and receive the medications at an infusion clinic. This plan allows you to avoid the ER when you have an extreme migraine attack.

Alternative Treatments

Depending on the symptoms and how you responded in the past, other treatments could also be used. These include triptans, anti-seizure drugs and different oral medications. Your doctor may recommend nerve blocks or trigger point injections. These headache management procedures aim to stop or reduce head and facial pain by “shutting down” overactive pain signals or reducing referred pain, respectively.

Behavioral therapies like mindfulness, biofeedback—an alternative to medicine that helps people alter the way their body functions—or relaxation techniques can help calm the brain and body. “You have the physical component, what you’re actually feeling, but pain also comes with an emotional component, and sometimes the emotional component actually adds extra distress and extra disability because it’s scary,” says Dr. Robblee. “Using those techniques helps give you a little bit of control.”

No matter what treatment you try, Dr. Robblee offers hope and support to those with migraine. “There’s always something that we can do,” she says. “Even though these attacks are scary and horrible, and often you feel like you’ve tried everything, believe me, there are still things we can try.”

The American Migraine Foundation is committed to improving the lives of those living with this debilitating disease. For more of the latest news and information on migraine, visit the AMF Resource Library. For help finding a healthcare provider, check out our Find a Doctor tool. Together, we are as relentless as migraine.