Toradol (Ketorolac) for Acute Headache
Ketorolac 30-60 mg IM/IV is highly effective for acute moderate to severe headache and should be your first-line parenteral NSAID, ideally combined with metoclopramide 10 mg IV for synergistic analgesia. 1
Dosing and Administration
- Administer ketorolac 30 mg IV or 60 mg IM for patients under 65 years of age 1
- Reduce dose to 30 mg IM for patients ≥65 years or with renal impairment 1
- Ketorolac provides rapid onset of action with approximately 6 hours of duration, making it ideal for severe headache with minimal risk of rebound headache 1
- Maximum duration of use is 5 days for all ketorolac formulations combined, as prolonged use increases frequency and severity of adverse reactions 2
Optimal Combination Therapy
- The most effective IV headache cocktail combines ketorolac 30 mg IV plus metoclopramide 10 mg IV 1
- Metoclopramide provides direct analgesic effects through central dopamine receptor antagonism beyond its antiemetic properties, creating synergistic pain relief 1
- Prochlorperazine 10 mg IV is an alternative to metoclopramide with comparable efficacy 1
Evidence Supporting Ketorolac
- Ketorolac 60 mg IM demonstrated equivalent efficacy to chlorpromazine 25 mg IV in treating acute migraine, with mean pain scores decreasing from 4.07 to 0.73 in 2 hours, without significant side effects 3
- In tension-type headache, ketorolac 60 mg IM was significantly superior to placebo at 0.5 and 1 hour, and superior to meperidine at 2 hours 4
- All patients in an open-label emergency department trial improved sufficiently with ketorolac 60 mg IM to require no further emergent treatment 5
Critical Contraindications and Precautions
- Do not use ketorolac in patients with renal impairment (creatinine clearance <30 mL/min), history of GI bleeding, active peptic ulcer disease, or significant cardiovascular disease 1
- Avoid in patients with aspirin/NSAID-induced asthma 1
- Strictly limit use to no more than 2 days per week to prevent medication-overuse headache 1
When to Choose Alternative Agents
- If ketorolac is contraindicated, consider dihydroergotamine (DHE) as an alternative parenteral option 1
- For patients with contraindications to all NSAIDs and triptans, newer CGRP antagonists (rimegepant, ubrogepant, zavegepant) are appropriate alternatives 1
- Avoid opioids as they lead to dependency, rebound headaches, and eventual loss of efficacy 1, 6
Frequency Monitoring to Prevent Medication Overuse
- If the patient requires acute headache treatment more than twice weekly, immediately initiate preventive therapy rather than increasing frequency of acute medications 1
- This prevents the vicious cycle of medication-overuse headache, which paradoxically increases headache frequency to daily occurrence 1