Why Toradol May Not Help Your Headache
Toradol (ketorolac) is actually highly effective for many headache types, but it won't work if you have a primary migraine that requires migraine-specific therapy (triptans), if you're experiencing medication-overuse headache from frequent analgesic use, or if your headache has a secondary cause requiring different treatment. 1
When Ketorolac Works Well
Ketorolac is specifically recommended as a first-line parenteral NSAID for severe migraine with relatively rapid onset (approximately 15 minutes) and six hours of duration, making it ideal for abortive therapy with minimal rebound headache risk. 1 The evidence shows:
- For tension-type headaches: Ketorolac 60 mg IM demonstrates significant superiority over placebo at 0.5 and 1 hour, and outperforms meperidine at 2 hours. 2
- For migraine headaches: Ketorolac 60 mg IM shows equivalent efficacy to meperidine/hydroxyzine (60% vs 56% achieving great/complete relief at 60 minutes) and to chlorpromazine 25 mg IV (both reducing pain scores from ~4 to <1 in 2 hours). 3, 4
- Self-administered at home: 64% of ketorolac injections resulted in good response with significant pain reduction, with only 13% requiring emergency room escalation. 5
Why Ketorolac Might Fail
Migraine-Specific Pathophysiology
Some migraines require serotonin receptor agonists (triptans) rather than anti-inflammatory mechanisms. 1 If your headache involves moderate-to-severe migraine with aura, vascular instability, or specific neurological symptoms, NSAIDs like ketorolac address only the inflammatory component, not the underlying serotonergic dysfunction. 6
Medication-Overuse Headache (MOH)
If you're using acute headache medications more than twice weekly, you may have developed MOH, which creates a vicious cycle where analgesics paradoxically worsen headache frequency and intensity. 1 In this scenario, ketorolac won't work because the problem is medication withdrawal, not acute inflammation.
Timing of Administration
Ketorolac effectiveness drops dramatically if administered late in the headache attack. 7 The medication must be given early when pain is still mild to achieve optimal efficacy—delayed treatment reduces effectiveness regardless of the agent used. 7
Wrong Headache Type
Ketorolac has inadequate evidence (Level C) for certain presentations and is probably not effective for some secondary headache causes. 6 If your headache stems from:
- Intracranial pathology (mass, hemorrhage)
- Giant cell arteritis
- Idiopathic intracranial hypertension
- Cervicogenic headache with significant structural component
Then anti-inflammatory therapy alone won't address the underlying pathology. 8
The Correct Algorithm When Ketorolac Fails
Step 1: Rule out medication overuse - If using acute medications >2 days/week, stop all analgesics and initiate preventive therapy rather than escalating acute treatment. 1, 7
Step 2: Optimize combination therapy - Add metoclopramide 10 mg IV to ketorolac 30 mg IV for synergistic analgesia and improved gastric absorption. 1 This combination is first-line for severe migraine requiring IV treatment. 1
Step 3: Switch to migraine-specific agents - If ketorolac fails after 2-3 attempts with proper timing, escalate to triptans (sumatriptan, rizatriptan, or zolmitriptan) for moderate-to-severe attacks. 1, 7 Subcutaneous sumatriptan 6 mg provides the highest efficacy (59% complete pain relief at 2 hours). 1
Step 4: Consider alternative mechanisms - Try dihydroergotamine (DHE) if both NSAIDs and triptans fail, or newer CGRP antagonists (rimegepant, ubrogepant, zavegepant) when traditional agents are contraindicated or ineffective. 1, 7
Critical Pitfall to Avoid
Never increase ketorolac frequency in response to treatment failure. 1 This creates MOH and worsens outcomes. Instead, transition to preventive therapy (requiring 2-3 months for oral agents to show efficacy) while optimizing your acute treatment strategy with different medication classes. 1