multi colored pills for a migraine cocktail
Chronic Migraine,  Episodic Migraine,  Medication,  Migraine,  Science/Research,  Vestibular Migraine

Migraine Cocktail: A Comprehensive Guide

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 combined 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.

Triptans

Triptans are usually the go to medication for migraine 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 cause 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.  

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 rebound headaches. (2)

Acute Medication – TriptansBrand NameDosage
AlmotriptanAxert12.5mg tablet (limit 25mg/day)
EletriptanRelpax40mg tablet (limit 80mg/day)
FrovatriptanFrova2.5mg tablet (limit 5mg/day)
NaratriptanAmerge1-2.5mg tablet (limit 2 doses/day)
RizatriptanMaxalt10mg tablet or orally disintegrating tablet (limit 3 doses/day)
SumatriptanImitrex50-100 mg tablet, 40mg nasal spray (limit 200mg/day or 40mg nasal spray)
SumatriptanImitrex, STAT dose, Sumavel, DosePro, Alsuma4-6mg subcutaneous injection (limit twice a day)
Sumatriptan plus NaproxenTreximet85mg sumatriptan and 500mg Naproxen (limit 2 tablets/day)
ZolmitriptanZomig2.5-5mg dissolvable tablet; nasal spray 2.5-5mg (limit 10mg/day or one nasal spray)

Other Non-Triptan Acute Medications – First Line

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 occur 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 treat migraine attacks, they can be taken up to 15 days a month while avoiding rebound headaches. If the NSAID is compounded with another medication, such as 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. 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 talking about with our doctors. There is no risk of rebound with Timolol maleate solution, which is a beta blocker, and it acts quicker than the Timolol tablet that is successfully used as a preventive for migraine. 

Other Acute MedicationBrand NameDosage
Diclofenac potassium powderCambia50mg packet (limit 150mg/day)
Naproxen/Naproxen sodiumAleve, Anaprox220mg or 500mg dose (limit 1000mg/day)
Diclofenac Sodium Dr
75mg tablet (limit 2 tablets/day)
Excedrin Migraine
1-2 tablets (limit 4 tablets/day)
Prodrin
1-2 tablet (limit 5 tablets/day)
ibuprofenAdvil, Motrin400-800mg tablet dose (limit 2400mg/day)
Timolol Maleate, ophthalmic solution USP
0.5% solution – 1 drop in each eye (limit 2 drops per eye/day)

New Medications – Released 2020

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 and help them to work more effectively. 

New Medications 2020Brand NameDosage
UbrogepantUbrelvy50-100mg tablet (limit 200mg/day)
RimgepantNurtec75mg orally dissolving tablet (limit 75mg/day)
LasmiditanReyvow50,100, 200mg tablet (lmit 1 dose/day)

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 and Diclofenac are often combined into a migraine cocktail with an anti nausea med or antihistamine. 

Second Line TreatmentsBrand NameDosage
Diclofenac Sodium Dr

Voltaren

75mg tablet (limit 2 tablets/day)
DihydroergotamineMigranal nasal spray, DHE (generic)
KetorolacToradol, Sprix nasal spray60mg/2ml injection (limit 2/day)
Tablets (limit 2/day)
Nasal Spray – 1 spray in each nostril (limit 4 doses/day)
Steroids (Cortisone, Dexamethasone, Prednisone)Generic, Decadron, genericDexamethasone (1/2 – 1) 4mg tablet (limit 8mg/day)
Prednisone (1/2 -1) 20mg tablet (limit 40mg/day; 80mg max dose)
ErgotamineErgomar or CafergotDosage varies (1/2 – 1) tablet (limit 2 tablets/day)

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)

Controversial Rescue TreatmentsBrand NameDosage
ButalbitalPhrenilin, Fiorinal, Fioricet, Esgic, Fiorinal #31-2 tablets, maximum 4 tablets per day. Should be limited per day and month
Hydrocodone and AcetaminophenVicodin, NorcoLimited per day and per month.
Hydrocodone and ibuprofenVicoprofenLimited per day and per month.
Oxycodone, Meperidine, Tramadolgeneric, generic, UltramLimited per day and per month.

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. 

Anti nausea medicationsBrand NameAvailable Formulations
PromethazinePhenerganTablets, lozenges, suppositories
ProchlorperazineCompazineIV, tablets, long acting spansules and suppositories
MetoclopramideReglanTablet, IM, IV dose 5-10mg
TrimethobensamideTiganTablets, lozenges, suppositories
OdansetronZofranTablets and orally disintegrating tablets, dosages 4-8mg

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. There are two benzodiazepines that are not recommended due to their long acting effect which is not effective for treating vertigo and 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)

Vestibular Migraine RescuesBrand NameDosage
LorazepamAtivan0.5mg (lowest effective dose) up to twice a day
ClonazepamKlonopin0.5mg (lowest effecctive dose) up to twice a day
DiazepamValium2mg (lowest effective dose) up to twice a day
AlprazolamXanaxNot Recommended
ChlordiazepateLibriumNot Recommended
MeclizineDramamine, Bonine or Antivert25-50mg every 4-6 hours
DiphendyramineBenadrylFollow instructions on label
DimenhydrinateDramamine50mg every 4-6 hours
Timolol Maleate, ophthalmic solution USP
0.5% solution – 1 drop in each eye (limit 2 drops per eye/day)

Devices used for the treatment of attacks

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 new 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.

Devices – Acute MigraineBrand Name
Vagus Nerve StimulatorgammaCore
External Trigeminal Nerve StimulatorCefaly
Non-invasive neuromodulation deviceNerivio
Narrow band green light therapyAllay Lamp

Medications Used In The Emergency Department

While it is rarely recommended to seek help from the local hospital emergency room (ER), attacks occasionally warrant this step. 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 drives us to seek help as well. The medications listed below are commonly administered in the ER for treatment of migraine attacks. (17)

Medications used in the Emergency DepartmentBrand name
MetoclopramideReglan
ProcholorperazineCompazine
ChlorpromazineThorazine
DiphendramineBenadryl
SumatriptanImitrex
ZolmitriptanZomig
KetorolacToradol
DexamethasoneDecadron
Magnesium SulfateMgSO4

The Migraine Cocktail

We are often looking for the best 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 med 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 a 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 can’t use triptans due to a previous migrainous stroke and I’m allergic to aspirin. My use of my migraine cocktail progresses as the pain increases…if it isn’t taken care of with my first line of defense. I begin by taking ginger, Timolol eye drops, and use a CBD/Menthol roller and a migraine rollerball (20% off with NATUREMS19). I can usually tell within an hour if these will be successful. But, I have also been waiting two hours more frequently to see if a little more time will help. These four items are successful about 60% of the time. 

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 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 ReLeaf pack to help with the symptoms. A weighted blanket can help and I love using the Calm app for guided meditations. 

The 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.

Marina – I take ginger, use Timolol drops, grab my Huggaroo weighted neck wrap. Sometimes I take Excedrin to take the edge off the pain. At night before bed I take eletriptan (Relpax).

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. 

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.

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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?
Migraine Cocktail: A Comprehensive GuideMigraine Cocktail: A Comprehensive GuideMigraine Cocktail: A Comprehensive Guide

I began having migraine attacks when I was a teenager, but was never properly diagnosed until I was an adult. This began 18 years where I was chronic and mostly intractable, resulting in a migrainous stroke in the summer of 2014. By implementing the protocols from the Heal Your Headache book by Dr. David Buchholz and the Migraine Strong Treatment Pie, I have been able to reduce my migraine frequency to episodic and maintain that since 2015. The end result of continuing to practice these tools is being able to actively participate in my life as a wife, mother, family member and friend. My goal as a migraine advocate, educator, and wellness coach is to help others gain more control over migraine. Let us know how we can help.

2 Comments

  • Tiere

    Thanks for all this helpful information, especially what each team member has uniquely found helpful to her. Why is it not usually recommended to go to the ER?

    • Migraine Strong

      If you need to go to the ER, it’s best to have your doctor send you with specific orders. The ER is not a migraine friendly environment and frequently patients have reported that they didn’t have a good experience. If you go in with orders from your doctor, they are more likely to take you seriously and get you settled. The other side of that is if your doctor knows you feel the need to go to the ER to manage an attack, they might be more inclined to work out some other options for you to try at home before you need to make that trip. -eileen

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