What is the role of intravenous (IV) ketorolac and intravenous (IV) prochlorperazine in the treatment of acute migraine attacks in children?

Intravenous Ketorolac and Prochlorperazine for Acute Migraine Treatment in Children

Intravenous prochlorperazine is superior to intravenous ketorolac for treating acute migraine attacks in children, with prochlorperazine showing an 84.8% success rate compared to 55.2% for ketorolac. 1

Efficacy of IV Medications for Pediatric Migraine

• Prochlorperazine has demonstrated significantly higher effectiveness than ketorolac in direct comparison studies, with a 30% greater success rate in achieving pain reduction within 60 minutes 1
• Ketorolac (Toradol) has moderate efficacy (rated 3 out of 4) for migraine treatment but is generally reserved for severe migraines when other treatments fail 2
• Prochlorperazine (Compazine) can effectively relieve headache pain and is rated 4 out of 4 for efficacy in migraine treatment 2
• When combined with diphenhydramine to prevent akathisia, prochlorperazine has a relatively low treatment failure rate of only 14% 3

Dosing and Administration

• Ketorolac: 60 mg IM every 15-30 minutes with maximum dosage of 120 mg per day; treatment should not exceed five days 2
• Prochlorperazine: 25 mg orally or suppository with maximum of three doses per 24 hours; IV dosing is 0.15 mg/kg with maximum of 10 mg 2, 1
• Both medications are typically administered with IV fluids, which may provide additional benefit 1, 4

Comparative Studies and Treatment Algorithm

• In a randomized, double-blind trial comparing these medications, 84.8% of children receiving prochlorperazine achieved at least 50% pain reduction at 60 minutes compared to only 55.2% of those receiving ketorolac 1
• Among dopamine antagonists used for pediatric migraine, prochlorperazine has shown superior efficacy compared to metoclopramide and promethazine, with significantly lower rates of rescue medication requirements 5
• For acute migraine treatment in children:
  1. First-line: Ibuprofen or acetaminophen for mild to moderate attacks 6, 4
  2. Second-line: IV prochlorperazine (with diphenhydramine to prevent akathisia) for severe attacks or when oral medications fail 1, 3, 7
  3. Third-line: IV ketorolac if prochlorperazine is contraindicated or unavailable 1, 4

Contraindications and Adverse Effects

• Ketorolac contraindications: Aspirin/NSAID-induced asthma, pregnancy, cerebrovascular hemorrhage 2
• Ketorolac adverse effects: Edema, drowsiness, dizziness, GI upset, increased diaphoresis 2
• Prochlorperazine contraindications: CNS depression, use of adrenergic blockers 2
• Prochlorperazine adverse effects: Hypotension, tachycardia, arrhythmias, akathisia, pseudo-parkinsonism, tardive dyskinesia, dystonia, dizziness, xerostomia, constipation, urinary retention, blurred vision 2
• Both medications generally have low rates of significant adverse effects in the acute treatment setting 1, 3

Special Considerations

• Early treatment of acute migraine attacks is recommended for best results 6
• For children with significant nausea or vomiting, non-oral routes of administration are preferred 6
• Avoid overuse of acute medications to prevent medication-overuse headaches 6
• When treating pediatric migraine in the emergency department setting, prochlorperazine is the only treatment that has been studied in a randomized controlled trial and found to effectively reduce pain 7