Can ketorolac (intravenous) be given to children with an acute attack of migraine?

Ketorolac for Acute Migraine in Children

Ketorolac (Toradol) can be administered intravenously for acute migraine attacks in children as it has a relatively rapid onset of action and approximately six-hour duration, making it effective for abortive therapy of severe migraines with low risk of rebound headache. 1

Efficacy and Administration

• Intravenous ketorolac is commonly used for treating migraine headaches in children, though it's generally reserved for severe migraines 1
• The recommended dosage is 0.5 mg/kg intravenously (maximum 30 mg), though recent evidence suggests a ceiling effect where 15 mg may be as effective as 30 mg in children weighing at least 60 kg 2
• Ketorolac has a relatively rapid onset of action and duration of approximately six hours 1
• Unlike chronic use of other analgesics, ketorolac is unlikely to cause rebound headaches when used for acute treatment 1

Comparative Efficacy

• In direct comparison studies, intravenous prochlorperazine (0.15 mg/kg; maximum 10 mg) has shown superior efficacy to intravenous ketorolac for pediatric migraine treatment (84.8% vs 55.2% success rate at 60 minutes) 3
• Adding ketorolac to metoclopramide did not significantly improve pain scores compared to metoclopramide alone in pediatric migraine treatment 4
• Recent research indicates that intranasal ketorolac (1 mg/kg) may be non-inferior to intravenous ketorolac (0.5 mg/kg) for reducing migraine pain in children, offering a needle-free alternative 5

Treatment Algorithm for Pediatric Migraine

1. First-line treatment: The American Academy of Neurology recommends ibuprofen as first-line medication for acute migraine in children 6
2. For moderate-severe migraines: Consider ketorolac IV (0.5 mg/kg, maximum 30 mg) when oral medications are ineffective or not tolerated 1
3. Alternative options: For adolescents, consider triptans (sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral) 1, 6

Precautions and Contraindications

• Ketorolac is contraindicated in patients with aspirin/NSAID-induced asthma, pregnancy, and cerebrovascular hemorrhage 1
• Potential adverse effects include edema, drowsiness, dizziness, gastrointestinal upset, and increased diaphoresis 1
• Limit treatment duration to no more than five days 1

Practical Considerations

• Intravenous ketorolac requires placement of an IV line, which can be technically challenging and distressing for children 5
• Consider intranasal ketorolac as a needle-free alternative with similar efficacy 5
• For patients with accompanying nausea or vomiting, consider adding an antiemetic such as metoclopramide or prochlorperazine 1