Can I order a single intramuscular or intravenous dose of ketorolac (Toradol) for an adult with a severe migraine attack who has no contraindications to NSAIDs?

Can You Order Ketorolac (Toradol) for Migraines?

Yes, you can and should order ketorolac for severe migraine attacks—it is specifically recommended as a parenteral NSAID with rapid onset and minimal rebound headache risk, making it ideal for abortive therapy when oral medications are inadequate. 1

Evidence Supporting Ketorolac Use

• Ketorolac has a relatively rapid onset of action with approximately six hours of duration, making it particularly effective for severe migraine attacks requiring parenteral treatment. 1
• The American Academy of Family Physicians explicitly recommends ketorolac as generally reserved for abortive therapy of severe migraines, with rebound headache being unlikely compared to other analgesics. 1
• Ketorolac nasal spray (31.5 mg) demonstrated 72.5% pain relief at 2 hours and was superior to placebo (38.3%, P < .001) in a randomized controlled trial, with efficacy comparable to sumatriptan. 2
• For sustained relief, ketorolac achieved 49% sustained pain relief at 24 hours versus 20% for placebo (P < .001), outperforming even sumatripan for this outcome. 2

Dosing and Route Selection

• Standard IV/IM dose is 30 mg for adults under 65 years or 15-30 mg for patients ≥65 years or with renal impairment. 3
• Intranasal ketorolac (1 mg/kg, maximum 31.5 mg) is non-inferior to IV ketorolac for migraine pain reduction in children and represents a needle-free alternative. 4
• Subcutaneous administration at 30-60 mg IM/IV is the typical urgent care dose for adults. 3

Combination Therapy for Enhanced Efficacy

• Combining ketorolac 30 mg IV with metoclopramide 10 mg IV is recommended as first-line combination therapy for severe migraine attacks requiring intravenous treatment, providing rapid pain relief while minimizing side effects. 3
• This combination addresses both pain and nausea while providing synergistic analgesia through metoclopramide's central dopamine receptor antagonism. 3

Critical Safety Considerations

• Ketorolac should be used with caution in patients with renal impairment, history of GI bleeding, or heart disease. 3
• Contraindications include active GI bleeding, renal failure risk (creatinine clearance <30 mL/min), compromised hemostasis, and aspirin/NSAID hypersensitivity. 5, 6
• Duration should be limited to as few days as possible (maximum 5 days) to minimize risk of serious adverse events, which increase markedly with prolonged use, especially in elderly patients. 5, 6
• The overall risk of GI or operative site bleeding with ketorolac is only slightly higher than with opioids when used according to dosage guidelines. 6

Medication-Overuse Prevention

• Limit ketorolac use to no more than 2 days per week to prevent medication-overuse headache, which can paradoxically increase headache frequency and lead to daily headaches. 3, 7
• If acute treatment is needed more than twice weekly, initiate preventive therapy rather than increasing acute medication frequency. 3, 7

When Ketorolac May Be Less Effective

• One older study found IM ketorolac 30 mg was significantly less effective than meperidine 75 mg at one hour for severe migraine (P = .02), though this study used a lower dose and different comparator than current guidelines recommend. 8
• However, more recent evidence with intranasal ketorolac demonstrates efficacy comparable to triptans, and guidelines continue to recommend it as first-line parenteral NSAID therapy. 2, 3

Position in Treatment Algorithm

• Ketorolac is appropriate for moderate to severe migraine when oral NSAIDs have failed or when non-oral routes are needed due to nausea/vomiting. 1, 3
• For mild to moderate migraine without nausea, start with oral NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg) before escalating to parenteral ketorolac. 1, 7
• Avoid opioids, which lead to dependency, rebound headaches, and eventual loss of efficacy—ketorolac provides superior long-term outcomes. 3, 7