Ketamine Nasal Spray for Migraine Treatment
Ketamine nasal spray is not recommended as a standard treatment for migraine headaches, as current clinical guidelines explicitly suggest against ketamine for short-term migraine treatment. 1
Standard First-Line Treatments for Migraine
- NSAIDs (aspirin, ibuprofen, naproxen sodium) are recommended as first-line therapy for most migraine sufferers 2, 3, 1
- For patients with nausea or vomiting, antiemetics like metoclopramide (10 mg IV or orally) should be added to treat accompanying symptoms and improve gastric motility 4, 3
- Combination medications containing aspirin-acetaminophen-caffeine are effective for migraine treatment (note that acetaminophen alone is not recommended) 3, 1
- For patients with significant nausea/vomiting, non-oral routes of administration should be selected 2, 3
Second-Line Treatment Options
- Triptans (rizatriptan, naratriptan, sumatriptan, zolmitriptan) are recommended for patients who don't respond to NSAIDs 4, 2, 3
- Dihydroergotamine (DHE) nasal spray has good evidence for efficacy when nausea/vomiting is present early in the attack 3
Current Evidence on Ketamine for Migraine
- The U.S. Department of Veterans Affairs and Department of Defense Clinical Practice Guideline explicitly suggests against intravenous ketamine for migraine treatment 1
- A 2018 randomized, double-blinded, placebo-controlled trial found that low-dose ketamine (0.2 mg/kg IV) did not produce greater pain reduction compared to placebo for acute migraine 5
- Ketamine was associated with significantly greater generalized discomfort at 30 minutes compared to placebo 5
Limited Evidence for Ketamine in Specific Scenarios
- A 2023 retrospective study of intranasal ketamine for refractory chronic migraine found that 49.1% of patients reported it as "very effective," but 74% experienced at least one adverse event 6
- Ketamine has shown some benefit in treating severe, disabling auras in familial hemiplegic migraine, with 5 out of 11 patients experiencing reduced severity and duration of neurologic deficits 7
- For treatment-refractory headaches, a 2017 retrospective review found that subanesthetic ketamine infusions provided short-term benefit in 71.4% of patients, but sustained response was not statistically significant 8
Important Clinical Considerations
- Ketamine should be reserved only for patients with refractory chronic migraine who have failed other aggressive treatments 6
- Given the potential for overuse and adverse effects, appropriate safety precautions should be implemented if ketamine is used 6
- Limiting acute treatments to no more than twice weekly is important to prevent medication overuse headaches 2, 3
- Consider preventive therapy for patients with frequent or disabling migraine attacks 3, 1