For ER (Emergency Room) cases of status migrainosus, would you recommend Ketorolac (Ketorolac Tromethamine) 30 MG/ML Injection Solution?

Ketorolac for Status Migrainosus in the Emergency Room

Ketorolac tromethamine 30 MG/ML injection is recommended as an effective treatment option for status migrainosus in the emergency room setting, with efficacy rated as 3 out of 4 by clinical guidelines. 1

Efficacy and Administration

• Ketorolac is administered as 60 mg intramuscularly (IM) every 15-30 minutes with a maximum daily dosage of 120 mg 1
• Treatment duration should not exceed 5 days as per FDA guidelines 2
• Use the lowest effective dose for the shortest duration consistent with treatment goals 2

Mechanism and Benefits

• As an NSAID, ketorolac provides effective pain relief for migraine attacks
• Should be administered at the onset of migraine pain for optimal effectiveness 3
• Can be combined with metoclopramide (10mg) to improve absorption and reduce nausea 3

Clinical Evidence

• In clinical studies, ketorolac has shown variable success rates:
  • One study found an 11% success rate in rendering patients pain-free within 24 hours for status migrainosus 4
  • Another study demonstrated that ketorolac was as effective as chlorpromazine in treating acute migraine, reducing pain scores from 4.07 to 0.73 within 2 hours 5
  • However, an earlier study found ketorolac to be less effective than meperidine for severe migraine 6

Contraindications and Precautions

• Avoid in patients with:
  • Aspirin/NSAID-induced asthma
  • Pregnancy
  • Cerebrovascular hemorrhage
  • Significant renal impairment 1, 3
• Common side effects include:
  • Edema
  • Drowsiness
  • Dizziness
  • GI upset
  • Increased diaphoresis 1

Alternative Treatments for Status Migrainosus

• Corticosteroids are considered a treatment of choice for status migrainosus 1, 7
  • Short courses of rapidly tapering oral corticosteroids (prednisone or dexamethasone)
  • IV corticosteroids (methylprednisolone) as single or multiple doses
• Dopamine receptor antagonists (e.g., prochlorperazine) have high evidence for efficacy 8
• Combination therapy with multiple non-opioid medications from different drug classes is recommended 8
• Adequate fluid hydration is essential 8

Important Clinical Considerations

• For optimal treatment of status migrainosus, consider:
  1. Starting with ketorolac 60 mg IM
  2. Adding metoclopramide 10 mg for antiemetic effects and improved absorption
  3. If inadequate response, consider adding corticosteroids
  4. Ensure adequate hydration
  5. Limit treatment duration to maximum 5 days 1, 3, 2

Pitfalls to Avoid

• Do not exceed maximum daily dose of 120 mg ketorolac 1
• Do not continue treatment beyond 5 days due to increased risk of adverse effects 2
• Avoid opioids when possible as they are less effective than other medications and carry risks of CNS side effects, habituation, and addiction 8
• Be aware that most patients with migraine may not derive sustained relief after emergency department treatment and may experience headache recurrence 8