Migraine Cocktail: Your Comprehensive Guide and Helpful How To Tips

According to the Migraine Research Foundation (MRF), migraine affects one billion people across the globe, 39 million in the United States alone, and it’s the 6th most disabling illness in the world. Finding an effective migraine cocktail is one of the single most important things that anyone with migraine can hope to find. 

Everyday we have conversations about acute medications in the Migraine Strong Facebook group. Which ones work best, what can be used together and just how many triptans are there on the market? I hope having all of this information in one place will be helpful for anyone treating migraine or trying to put together an effective migraine cocktail. I’ll also share some migraine cocktails that we personally use and the medications that are typically used to treat vestibular migraine.

** Disclaimer: This is written from the perspective of the patient and patient-advocate. This is not a substitute for medical advice. The information here will help you understand your many options so that you are better prepared for the next conversation you have with your healthcare provider.

What is a migraine cocktail?

Simply put, a migraine cocktail is a combination of prescribed, over-the-counter and/or natural remedies that are used to effectively stop the attack.

There are some useful home remedies that can be used alone or in combination with medications your doctor prescribes. No medications, prescribed or OTC should be used together without first consulting your doctor or pharmacist.

Triptans

These medications are usually the go to medication for inclusion in a migraine cocktail, after the typical over the counter (OTC) medications have been tried. “Triptans act by constricting blood vessels and blocking the release of calcitonin gene-related peptide (CGRP) from the nerves activated during migraine. CGRP causes blood vessels to swell and initiates the cascade of inflammatory events leading to pain.” (1) There are currently seven different triptan medications with several different formulations. Most patients receive sumatriptan (Imitrex) as the first triptan to try.  

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Efficacy

Unfortunately, if side effects are too annoying or the medication doesn’t work, people are often left with the idea that triptans ‘don’t work’ for them. The involvement of digestive issues can also cause the migraine medication to not be absorbed. Experimenting with injection and nasal spray formulations may prove to be the difference in getting relief and not.

Also, all triptans are formulated differently. If sumatriptan (pills, nasal spray or injections) doesn’t work, it’s worth trying eletriptan (Relpax), rizatriptan (Maxalt), almotriptan (Axert) or zolmitriptan (Zomig nasal spray). Trying these in conjunction with other medications in a migraine cocktail can make them more effective as well. Triptans should be limited to no more than 10 days a month or approximately twice per week to avoid the risk of rebound headaches. (2)

Other non-triptan acute medications –

The other non-triptan medications used for the acute treatment of migraine attacks are non steroidal anti inflammatories (NSAIDs). These medications also come in different formulations and can be tried to see what might work best. Three of these are OTC medications. NSAIDs block the inflammation that occurs during a migraine attack. They can also help more when the attack is full blown than a triptan will, such as an early morning attack that started during the night. Combined with a triptan, this migraine cocktail will block both pain pathways and can provide more complete relief. (3)

If using just NSAIDs to make a migraine cocktail at home, they can be taken up to 15 days a month while avoiding the risk of rebound headaches. If the NSAID is compounded with another medication, such as in Excedrin Migraine and Prodrin, then they should be limited to 10 days per month.

Timolol maleate eye drops might be a little bit of a surprise in this category. Timolol can be effective part of a migraine cocktail. It has been shown, in a small study, to help treat migraine symptoms. (4) We have found this to be true with many members of the Migraine Strong community and think it is worth discussing when trying to find a better treatment. There is no risk of rebound with Timolol maleate solution, which is a beta blocker. Also, it acts quicker than the Timolol tablet that is successfully used as a preventive for migraine. 

Read our article on Benadryl for migraine to see how effective it can be in an at home migraine cocktail.

New migraine specific medications

Over the past several years, we have added a few migraine specific acute medications to our migraine tool kits. Two (Ubrelvy and Nurtec) are CGRP blockers and Reyvow works similarly to a triptan without affecting as many serotonin receptors or causing vasoconstriction. Many headache specialists recommend taking these early on in an attack in an effort to increase their efficacy. They can also be combined with other medications like NSAIDs to make a migraine cocktail at home and help them to work more effectively. 

Trudhesa is a new application of an old medication. DHE (dihydroergotamine) has been around for a long time, but Trudhesa has an innovative new approach to administering it. The nasal spray is specially designed to be dispensed into the upper nasal cavity which allows for better absorption. It can also be taken anytime during the migraine attack instead of being limited to efficacy only when taken early. This method of administering the medication allows patients to bypass the GI system which is often affected by migraine attacks.

Second line treatments

These treatments are used once the first line acute treatments have been exhausted and we need to try something different to bring relief. These rescue treatments have different levels of effectiveness. Ketorolac or Diclofenac are often combined into a migraine cocktail with Benadryl or with an anti nausea med or antihistamine. 

Controversial rescue treatments

The following medications are generally not recommended for the treatment of migraine. This is due to the risk of dependence, addiction and rebound headaches. These medications are sometimes prescribed when all of the other first line treatments have failed. They should be used sparingly. Dr. David Watson, a neurologist and director of the Headache Center at the West Virginia School of Medicine, says ‘when taken every couple of months for a particularly severe migraine attack, opioids may be an effective treatment option for some patients.’ (5)

Studies have shown that opioids can induce central sensitization and rebound headaches. (6) These medications can trigger rebound headaches when taken four times or more a month and should be used as a rescue only after all other therapies have failed. (7)

Anti-nausea medications

These medications can be very helpful for those of us that have nausea as a primary symptom of our migraine attacks. There are several different methods for intake that don’t require going through the GI system which is frequently very sluggish or non functioning during an attack. Being able to opt for a suppository or injection can make a world of difference.

Studies have found that these medications have a primary effect on migraine besides their antiemetic properties. (8) They are frequently combined with NSAIDs and/or triptans to make a migraine cocktail. Our article about reglan for migraine, written by Dr. Thomas Berk, details how these medications can help in a migraine cocktail.

Vestibular migraine rescue medications 

The dizziness that accompanies vestibular migraine can be treated with the medications listed below. Generally, starting at the lowest dose to see how effective it is will reduce the risk of dependence. Long acting benzodiazepines (Xanax) are not recommended because they are ineffective for treating vertigo. Also there is the potential for difficult withdrawal syndrome for Xanax. (9) Timolol eye drops are also effective at treating dizziness from a vestibular migraine attack due to their rapid route of delivery. (10) Meclizine, diphendramine (Bendryl)and dimenhydrinate are all options to add to an OTC migraine cocktail.

Devices used for the treatment of attacks

Adding a device to a migraine cocktail has become more available in recent years. The gammaCore vagus nerve stimulator has been shown to treat both migraine (11) and vestibular migraine attacks (12). The Cefaly device has also been shown to treat migraine and vestibular migraine attacks. (13) A study conducted on Nerivio showed that it was effective in treating migraine pain and the most bothersome symptom at the 2 hour mark. (14) Read our review of the Allay Lamp which is a newish addition to the market. This lamp, which has a narrow band of green light, has been shown to be soothing for people with migraine. (15) Personally, I find it effective at reducing my overall migraine symptoms, including nausea, pain and light sensitivity.

Medications used in the emergency department

While it is rarely recommended to seek help from the local hospital emergency room (ER) for a migraine attack, occasionally this step is warranted. If you can’t stop vomiting and are dehydrated, that is a good time to seek out help from the ER.

You should go to the ER if you feel like you are having the worst headache of your life, you are having symptoms of a stroke which are not common for your type of migraine or you have a thunderclap headache that reaches its peak of pain inside of 60 seconds. This can be a sign of a very serious situation like bleeding within the brain. (16) Sometimes severe, intense and unrelenting pain and vomiting drives us to seek help as well. The medications listed below are commonly administered in the ER, as a migraine cocktail, for treatment of migraine attacks. (17)

OTC migraine cocktail

We are often looking for the best at home migraine cocktail we can find to help us treat our attacks. This looks different for everyone. The most common migraine cocktail that we see is a triptan and naproxen or naproxen sodium. Naproxen sodium is absorbed more rapidly than naproxen. ‘The body reaches peak levels of naproxen in 2–4 hours and naproxen sodium in 1–2 hours, meaning that it absorbs naproxen sodium faster than regular naproxen.’ (18) But we also see where doctors have recommended adding another medication like an anti-nausea medication or Benadryl to that migraine cocktail as well. Some of that has to do with absorption if the stomach is not able to absorb medications. But the anti-nausea medications can also help with the primary head pain. 

The migraine cocktails below have developed after years of being chronic where taking a dose of potentially rebound causing medication had to be monitored. These are stepped approaches that tend to work for us because, just like many of you, we have to limit the number of rebound causing medications per month. If you are episodic, and not close to the maximum number of medications you can take per month, hitting the attack with the most effective medication first makes the most sense.

My migraine cocktail

If my migraine attack is slow progressing, then attempting several therapies can be worthwhile. My attacks tend to progress slowly and last for a long time, especially if left untreated. I start with Ubrelvy which can be effective for me if taken at the very first sign of an attack. There is a very narrow window for this to work, so if I already feel any type of pain in my eye, it is too late.

At that point, I move on by taking ginger, turning on my Allay lamp, Timolol eye drops, and use a migraine stick. I can usually tell within an hour if these will be successful. If the attack is coming on fast, I immediately take Frovatriptan and drink some caffeine. This is very effective for me, but very expensive with my insurance.

The second line of treatment

If I need some more help, I move on to the rest of my migraine cocktail which includes Diclofenac Sodium DR, Flexeril and Phenergan. While Flexeril isn’t part of the list above, it has been helpful in treating my migraine attacks. I have tried samples of Diclofenac Potassium (Cambia) before, but my insurance won’t approve them.

I usually need to lie down for this part of the migraine cocktail to work. I usually use either a heating pad, ice pack or the Migrafreeze Migraine Relief Hat (15% off with code Freeze15) to help with the symptoms. And I love using the Calm app for guided meditations. 

The Migraine Strong team’s migraine cocktails

Jennifer – I begin by taking ginger, Timolol eye drops, Lord Jones CBD lotion and/or tincture and a migraine rollerball. I also take an extra magnesium glycinate or do a magnesium foot soak in hopes to calm vestibular symptoms. If things continue to escalate. I take naproxen, reglan and, I know this will be controversial but coffee. Naproxen and caffeine together help me. I use ice on my head (Huggaroo face mask/ Koldtec halo) and heat (Huggaroo neck wrap or heating pad) on my neck. If it still continues, I’m usually vomiting by this time so I add zomig nasal spray.

Danielle – If I get aura, I wait until I start to feel head pain as sometimes I get aura with nothing else and I don’t need to intervene. If I feel pain after aura I go straight to my sumatriptan. If I don’t have aura and have migraine symptoms starting, I have a big cup of caffeinated coffee and ginger capsules if it’s before 2:00 pm, otherwise the caffeine will keep me up at night. If it’s after 2:00 I will try ginger.

If things still escalate, within an hour of trying non-meds, I take Aleve. If I get any jaw pain, I know it will become a full, bad attack so I don’t hesitate to take sumatriptan. Since my attacks are in better control now, sumatriptan always works on it’s own. I’m lucky! A few years ago, when my attacks were more frequent, more intense and longer, I combined sumatriptan with Aleve and Benadryl as the attack required a bigger punch to knock it out. I’m grateful that I can often avoid my prescription meds now. My migraine cocktail at home with Benadryl and Aleve or Advil often do the trick. Benadryl is always in my migraine kit.

Finding help for migraine

If you have migraine that is not responding to over the counter medications or if your attacks are happening more than 4 times a month, seek the help of a specialist to help manage your attacks. Understanding the possibility and mechanics of moving from episodic migraine to chronic migraine is the key to stopping that process. Avoiding the chronification of migraine is so important for long term migraine care. If you would like to find a headache specialist, the American Migraine Foundation has a tool to help you find one in your area. If one isn’t close, find a neurologist or another doctor that has a passion for helping you manage your migraine attacks. You can also check out our review of the Neura Health App to see a headache specialist online.

As always, follow us on Instagram and Facebook for educational information. Join our private Facebook group to interact with others who are in the same boat and completely understand what you are going through. Let us know how we can help.

Updated from the original publish date of 6/11/2020.

References:

1. Use of Beta-Blocker Ophthalmic Solution for the Treatment of Migraine
2. American Migraine Foundation, Facebook Live recap
3. American Migraine Foundation Acute Treatments For Migraine
4. Beta Blocker Eye Drops For Treatment of Acute Migraine
5. Spotlight On: Migraine and the Opioid Crisis
6. Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action
7. American Migraine Foundation, Facebook Live recap
8. Migraine Treatment: Current Acute Medications and Their Potential Mechanisms of Action
9. Drug Treatment of Vertigo
10. Timolol Eye Drops Effective In Some Patients with Acute Migraine
11. Non-Invasive Vagus Nerve Stimulation – Migraine
12. Acute vestibular migraine treatment with noninvasive vagus nerve stimulation
13. External Trigeminal Nerve Stimulation: Potential Rescue Treatment for Acute Vestibular Migraine
14. Nerivio Migra Devices Shows Success Acute Migraine Treatment
15. Migraine Photophobia Originating in Cone-Driven Retinal Pathways
16. Thunderclap Headache
17. Pharmacotherapy for Primary Headache Disorder in the Emergency Department
18. What is Naproxen?