Role of Ketorolac in Acute Migraine Treatment
Ketorolac (Toradol) is an effective parenteral NSAID with relatively rapid onset of action and approximately six hours of duration that is generally reserved for abortive therapy of severe migraines, with the advantage that rebound headache is unlikely. 1, 2
Position in Treatment Algorithm
- For mild to moderate migraine attacks, oral NSAIDs are recommended as first-line treatment 2, 3
- For moderate to severe migraine attacks or those with poor response to oral NSAIDs, migraine-specific drugs (triptans, DHE) or combination therapies are preferred 1
- Parenteral ketorolac (30-60mg IM/IV) is particularly valuable for severe migraine attacks requiring emergency or urgent care treatment 2
- Ketorolac is often used in combination with antiemetics like metoclopramide or prochlorperazine for enhanced efficacy in severe migraine 2
Evidence for Efficacy
- Ketorolac has been shown to be as effective as chlorpromazine in treating acute migraine, with mean pain scores decreasing from 4.07 to 0.73 within 2 hours 4
- When administered as a nasal spray (31.5mg), ketorolac demonstrated superior efficacy to placebo and non-inferiority to sumatriptan nasal spray for 2-hour pain relief (72.5% vs 69.4%) 5
- Ketorolac provides comparable analgesia to opioids like morphine and pethidine in various acute pain settings, including migraine 6
- Ketorolac may have a slightly delayed onset compared to some treatments but often provides longer-lasting relief 6
Advantages of Ketorolac
- Unlike opioids, ketorolac does not cause dependency or lead to medication overuse headaches when used appropriately 1
- Ketorolac is particularly useful when significant nausea or vomiting accompanies migraine, as it can be administered parenterally 2
- The parenteral route ensures reliable absorption when oral medications may be compromised by migraine-associated gastric stasis 2
- Ketorolac can be effective as rescue therapy when first-line treatments fail 1, 2
Limitations and Considerations
- In direct comparison with DHE plus metoclopramide, ketorolac provided moderate relief in 6 of 9 patients versus 8 of 9 with DHE/metoclopramide, suggesting DHE/metoclopramide may be slightly more effective 7
- When compared to dexamethasone plus metoclopramide, ketorolac showed faster initial pain reduction but similar final efficacy at 2 hours 8
- As with other NSAIDs, ketorolac carries risks of gastrointestinal, renal, and hematological adverse effects, particularly with prolonged use 6
- Ketorolac should be used with caution in elderly patients and those with renal impairment, history of GI bleeding, or heart disease 2
Optimal Use in Practice
- Ketorolac is most appropriate for severe migraine attacks, particularly in emergency or urgent care settings 2
- The recommended dosage is 30mg IV or 60mg IM for patients under 65 years, with reduced doses for older patients or those with renal impairment 2
- Combining ketorolac with an antiemetic like metoclopramide (10mg IV) or prochlorperazine (10mg IV) provides synergistic analgesia and treats accompanying nausea 2
- Treatment should begin as early as possible during an attack to maximize efficacy 2
- Ketorolac should be limited to short-term use (≤5 days) to minimize risk of adverse effects 6
Common Pitfalls to Avoid
- Overuse of ketorolac beyond recommended duration (>5 days) significantly increases risk of adverse effects, especially in elderly patients 6
- Failure to consider ketorolac as an alternative when triptans are contraindicated or ineffective 2
- Not utilizing the parenteral route when significant nausea/vomiting is present 2
- Using ketorolac in patients with contraindications such as active peptic ulcer disease, severe renal impairment, or history of hypersensitivity to NSAIDs 6