From the Guidelines
Ketorolac has moderate-quality evidence supporting its use in migraine treatment, particularly for acute migraine attacks. The evidence from the study 1 suggests that ketorolac is an option for the treatment of mild to moderate migraine attacks or severe attacks that have been responsive in the past to similar agents.
Key Points
- Ketorolac is listed as an NSAID option with an efficacy rating of 3, indicating moderate effectiveness in the treatment of migraine headaches 1.
- The recommended dosage of ketorolac is 60 mg IM every 15 to 30 minutes, with a maximal dosage of 120 mg per day, and treatment should not exceed five days 1.
- Ketorolac should be used with caution in patients with aspirin/NSAID-induced asthma, pregnancy, or cerebrovascular hemorrhage, and its use is associated with potential adverse reactions such as edema, drowsiness, and GI upset 1.
- While the study 1 does not specifically address the use of ketorolac in migraine status, it does mention that steroid therapy may be considered for patients with status migrainosus, but the evidence for this is insufficient.
- The use of ketorolac in clinical practice should prioritize caution, especially in patients with renal impairment, gastrointestinal bleeding risk, or those on anticoagulants, and should not exceed 5 days of continuous use due to potential renal and gastrointestinal side effects.
Considerations
- The evidence for ketorolac in migraine treatment is based on its classification as an NSAID and its efficacy rating in the study 1.
- The study 1 provides a comprehensive overview of the management of acute migraine headaches, including the use of NSAIDs, combination analgesics, and migraine-specific drugs.
- The quality of evidence for ketorolac in migraine treatment is moderate, and its use should be guided by clinical judgment and consideration of individual patient factors.
From the Research
Quality of Evidence for Ketorolac in Migraine Status
The quality of evidence for ketorolac in migraine status can be evaluated based on several studies:
- A systematic review and meta-analysis published in 2022 2 found that ketorolac may have similar efficacy to phenothiazines and metoclopramide in treating acute migraine headache, but may offer better pain control than sumatriptan, dexamethasone, and sodium valproate.
- Another systematic review published in 2013 3 found that ketorolac is an effective alternative agent for the relief of acute migraine headache in the emergency department, with similar pain relief to meperidine and more effective than sumatriptan.
- A randomized trial published in 2016 4 found that ketorolac nasal spray is superior to placebo and non-inferior to sumatriptan nasal spray for the acute abortive treatment of migraine.
- An updated systematic review and meta-analysis published in 2024 5 found that intravenous ketorolac and metoclopramide have similar effects for migraine patients, with no significant differences in pain intensity, sustained headache relief, or adverse effects.
- A systematic review and meta-analysis published in 2021 6 found that nonsteroidal anti-inflammatory drugs, including ketorolac, are significantly associated with reduced pain at 2 hours and 1 day, and increased risk of mild and transient adverse events.
Key Findings
- Ketorolac may have similar efficacy to phenothiazines and metoclopramide in treating acute migraine headache 2.
- Ketorolac is an effective alternative agent for the relief of acute migraine headache in the emergency department 3.
- Ketorolac nasal spray is superior to placebo and non-inferior to sumatriptan nasal spray for the acute abortive treatment of migraine 4.
- Intravenous ketorolac and metoclopramide have similar effects for migraine patients 5.
- Nonsteroidal anti-inflammatory drugs, including ketorolac, are significantly associated with reduced pain at 2 hours and 1 day, and increased risk of mild and transient adverse events 6.