What is the role of ketamine in treating migraines?

Ketamine's Role in Migraine Treatment

Intravenous ketamine is not recommended for the short-term treatment of migraine headaches based on current evidence. 1

Current Evidence on Ketamine for Migraines

• The 2023 U.S. Department of Veterans Affairs and Department of Defense Clinical Practice Guideline explicitly suggests against intravenous ketamine for the short-term treatment of migraine (weak against recommendation) 1
• Limited high-quality randomized data exists to support ketamine as a second-line therapy for migraines 2
• Most published data to date demonstrate no established role for ketamine in routine migraine management 2

First-Line Treatments for Migraines

Instead of ketamine, the following treatments are recommended for migraine:

• First-line therapy: NSAIDs (aspirin, ibuprofen, naproxen sodium) for most migraine sufferers 1
• Strong recommendations for the short-term treatment of migraine include:
  • Triptans: eletriptan, frovatriptan, rizatriptan, sumatriptan (oral or subcutaneous), zolmitriptan (oral or intranasal) 1
  • Combination of sumatriptan and naproxen 1
  • Aspirin-acetaminophen-caffeine combination 1
• Weak recommendations for short-term treatment include:
  • Simple analgesics: acetaminophen, aspirin, ibuprofen, or naproxen 1
  • Newer agents: rimegepant or ubrogepant 1

Potential Role of Ketamine in Refractory Cases

While not recommended for routine use, some research suggests potential benefits in specific scenarios:

• Ketamine has been studied in refractory chronic migraine cases when all other treatments have failed 3, 4
• Small case series have shown short-term improvement in pain severity with intravenous ketamine in hospitalized patients with refractory chronic migraine 4
• In one retrospective review, 71.4% of patients with treatment-refractory headache showed at least a 2-point improvement in pain scores after ketamine infusion 5

Limitations and Concerns

• Ketamine's efficacy for migraine remains unproven in high-quality clinical trials 6
• Questions remain regarding its overall efficacy, appropriate dosing, and risk of side effects 6
• Potential adverse effects include dissociative symptoms and hallucinations 4
• Current evidence is insufficient to incorporate ketamine into routine migraine management 6

Clinical Approach to Migraine Management

1. Begin with NSAIDs for most migraine sufferers 1
2. For patients who don't respond to NSAIDs, use migraine-specific agents (triptans, DHE) 1
3. For patients with significant nausea/vomiting, select non-oral routes of administration and consider antiemetics 1
4. Consider preventive therapy for patients with frequent or disabling attacks 1
5. Reserve experimental treatments like ketamine only for truly refractory cases in specialized settings 3, 4

Key Takeaway

While ketamine shows some promise in highly refractory migraine cases, current clinical guidelines and evidence do not support its use as a standard treatment for migraine headaches. Clinicians should adhere to established first-line and second-line therapies before considering ketamine for migraine management.