What is the preferred treatment for headaches, Toradol (ketorolac) or opioids?

Toradol vs Opioids for Headaches

Toradol (ketorolac) is strongly recommended over opioids for the treatment of headaches, including migraines, due to superior efficacy and safety profile. 1, 2

Treatment Algorithm for Headaches

First-Line Treatments

• For mild to moderate headaches:

  • Simple analgesics (acetaminophen)
  • NSAIDs:
    • Ibuprofen (400-600mg)
    • Naproxen sodium (500-550mg)
    • Ketorolac (Toradol): 60mg IM (not to exceed 120mg/day, treatment limited to 5 days) 3

• For moderate to severe migraines:

  • Triptans (sumatriptan 50mg orally or 6mg subcutaneously)
  • Combination therapy: triptan plus NSAID 1

Second-Line Treatments

• Antiemetics (metoclopramide, prochlorperazine)
• Ergot alkaloids
• Newer agents (gepants, ditans) 2

Why Toradol is Preferred Over Opioids

1. Efficacy:

   • Ketorolac demonstrates strong analgesic activity comparable to opioids for headache management 4, 5
   • In controlled trials, ketorolac was significantly better than placebo at 0.5 and 1 hour and better than meperidine (an opioid) at 2 hours for tension headaches 5

2. Safety Profile:

   • The American College of Physicians explicitly recommends avoiding opioids for acute migraine treatment due to risk of dependence and lack of efficacy 1
   • Ketorolac does not cause respiratory depression, sedation, or dependence issues associated with opioids 4, 6

3. Duration of Action:

   • Ketorolac's analgesic effect may be slightly delayed but often persists longer than opioids 4

4. Reduced Side Effects:

   • Opioids commonly cause nausea, vomiting, constipation, sedation, and respiratory depression
   • Ketorolac avoids these specific side effects 4, 6

Appropriate Dosing of Ketorolac

• Intramuscular: 60mg IM every 15-30 minutes (maximum 120mg/day) 3
• Treatment duration: Not to exceed 5 days 3

Important Cautions and Contraindications

Ketorolac Contraindications

• Aspirin/NSAID-induced asthma
• Pregnancy
• Cerebrovascular hemorrhage
• Renal impairment
• Bleeding disorders 3

Monitoring for Ketorolac

• Gastrointestinal effects (most common adverse events)
• Renal function
• Bleeding risk (especially with prolonged use) 4

Opioid Limitations

• The American College of Physicians strongly recommends against opioids for migraine treatment 1
• Risk of medication overuse headache and dependence
• Not recommended unless other options have been ineffective 2

Special Considerations

• Medication Overuse Prevention: Limit acute medications to prevent medication overuse headache:

  • NSAIDs: No more than 15 days per month 1
  • Opioids: Avoid if possible

• Combination Therapy: When severe pain requires opioids, combining with ketorolac can reduce opioid requirements by 25-50%, decreasing opioid-related adverse events 4

Ketorolac provides a potent non-opioid alternative for headache management with comparable efficacy to opioids but without the risks of dependence, respiratory depression, and other serious side effects associated with opioid use.