Is Toradol (ketorolac) suitable for pain management in a hypertensive patient with a headache, given improved blood pressure control from severe hypertension to mild hypertension?

From the Guidelines

Toradol can be cautiously given to this hypertensive patient with headache whose blood pressure is now better controlled at 160/90, but with close monitoring of blood pressure and limited to a maximum of 5 days of use. A single dose of Toradol 10-30mg IV or 10mg orally is reasonable for short-term pain management, as it has a relatively rapid onset of action and a duration of approximately six hours 1. However, several precautions should be considered, as Toradol is an NSAID that can potentially worsen hypertension or interfere with antihypertensive medications by causing sodium retention and vasoconstriction. The patient should be monitored for further blood pressure changes after administration. Some key points to consider when using Toradol for pain management in this patient include:

• The risk of rebound headaches is unlikely with Toradol, but overuse of analgesics can lead to rebound headaches 1
• Alternative pain management options like acetaminophen might be safer for long-term use in hypertensive patients, although acetaminophen alone has not been shown to be beneficial in migraine treatment, but it is effective in combination with aspirin and caffeine 1
• Opioid analgesics such as meperidine and butorphanol are sometimes required to abort severe migraines, but narcotic use should be avoided for chronic daily headaches because it can lead to dependency, rebound headaches, and eventual loss of efficacy 1
• The lowest effective dose of Toradol should be given for the shortest duration possible while continuing to monitor blood pressure closely.

From the FDA Drug Label

NSAIDs, including ketorolac tromethamine, can lead to onset of new hypertension or worsening of preexisting hypertension, either of which may contribute to the increased incidence of CV events. Patients taking thiazides or loop diuretics may have impaired response to these therapies when taking NSAIDs NSAIDs, including ketorolac tromethamine, should be used with caution in patients with hypertension. Blood pressure (BP) should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy

The patient has a history of hypertension with a recent blood pressure reading of 223/155, now controlled at 160/90. Given the information from the drug label, ketorolac tromethamine should be used with caution in patients with hypertension. The patient's blood pressure should be monitored closely during the initiation of NSAID treatment and throughout the course of therapy. It is recommended to use the lowest effective dose for the shortest duration possible to minimize the potential risk for an adverse CV event. 2

From the Research

Hypertensive Patient with Headache

Toradol for Pain Management

• Toradol, also known as ketorolac, is a nonsteroidal anti-inflammatory drug (NSAID) that can increase blood pressure in patients with hypertension 3.
• The use of NSAIDs, including Toradol, can limit the effectiveness of antihypertensive drugs and increase the risk of cardiovascular disease, stroke, and end-stage renal disease 3, 4.
• Alternative analgesics that do not affect prostaglandin synthesis, such as acetaminophen, tramadol, and narcotic analgesics, may be considered for patients with hypertension 3.

Blood Pressure Control

• The patient's blood pressure is currently under control at 160/90, but was originally 223/155, indicating a significant reduction in blood pressure 3, 4.
• Regular exercise, such as aerobic exercise, can help lower blood pressure and reduce the risk of cardiovascular disease 5, 6.
• However, the use of NSAIDs, including Toradol, can counteract the blood pressure-lowering effects of exercise and antihypertensive medication 3, 4.

Alternative Pain Management Options

• Acetaminophen may not be a suitable alternative for patients with hypertension, as recent studies suggest it can also increase blood pressure 7.
• Tramadol and narcotic analgesics may be considered as alternative pain management options for patients with hypertension, but their use should be carefully monitored and individualized 3.