Can a patient with a 1-week migraine who received a Toradol (ketorolac) and Decadron (dexamethasone) injection 1 week ago and did not respond to Nurtec (rimegepant) receive another injection?

Management of Persistent Migraine After Toradol and Decadron Injection

A second Toradol (ketorolac) and Decadron (dexamethasone) injection can be administered for a persistent migraine after one week, as this is a reasonable approach for a patient who has not responded to initial therapy and Nurtec (rimegepant). 1, 2

Acute Migraine Treatment Options

When first-line treatments fail, the following approach is recommended:

1. For patients with persistent migraine (>1 week):

   • A second round of parenteral therapy is appropriate when:
     • At least 7 days have passed since the first injection
     • The patient has not responded to oral medications
     • The migraine continues to impact quality of life

2. Alternative treatments to consider:

   • Strong recommendation for triptans (sumatriptan, rizatriptan, eletriptan) 1
   • Strong recommendation for aspirin-acetaminophen-caffeine combination 1, 2
   • Weak recommendation for NSAIDs (ibuprofen, naproxen) 1

Specific Guidance on Repeat Injections

• Ketorolac (Toradol) has been shown to provide significant pain reduction in migraine patients 3
• Dexamethasone (Decadron) has demonstrated effectiveness in preventing migraine recurrence 4
• The combination of these medications addresses both pain relief and prevention of recurrence

Important Considerations and Precautions

• Monitor for side effects: Ketorolac can cause gastrointestinal issues and renal effects with repeated use
• Limit frequency: Avoid regular, frequent administration of parenteral ketorolac
• Evaluate for medication overuse: Ensure patient is not developing medication overuse headache (limit NSAIDs to ≤15 days/month) 2

Follow-up Plan After Second Injection

If the patient continues to have inadequate response after the second injection:

1. Consider preventive therapy options:

   • Strong recommendations for erenumab, fremanezumab, or galcanezumab 1
   • Consider candesartan or telmisartan 1, 2
   • Topiramate may be effective for prevention 1

2. Re-evaluate diagnosis and treatment approach:

   • Look for "red flags" suggesting secondary headache
   • Consider neurology referral for refractory migraine

Regarding Nurtec (Rimegepant)

• Rimegepant is approved for both acute and preventive treatment of migraine 5
• If the patient did not respond to a single dose of Nurtec, this does not rule out potential benefit from other acute treatments 5, 6
• There is insufficient evidence to recommend rimegepant for prevention of episodic migraine according to current guidelines 1

Practical Algorithm

1. Confirm ongoing migraine is same episode (not new attack)
2. Verify no contraindications to repeat injection
3. Administer second Toradol and Decadron injection
4. If inadequate response after second injection:
   • Initiate preventive therapy
   • Consider neurology referral
   • Evaluate for secondary headache causes

This approach prioritizes effective pain relief and improved quality of life while maintaining appropriate safety measures for medication administration.