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Does Ketorolac Improve Your Migraine Cocktail?

October 3, 2022

Written by Amanda Mathews

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This systematic review found IM or IV ketorolac had similar efficacy in treating acute migraine headache as phenothiazines and metoclopramide but was unable to draw significant conclusions about ketorolac in comparison to other therapies or as part of a multi-drug cocktail due to paucity of evidence.

Why does this matter?
Headaches account for approximately 3% of ED visits. Many providers have a “migraine cocktail” that includes ketorolac for the initial treatment of migraine headaches in the ED. Does ketorolac offer effective pain relief for migraines in this patient population?

What did the farmer with a headache say after someone stole his wheat?…No, mi-graines!
This was a systematic review and meta analysis that included 13 trials with a total of 944 participants. The authors looked at 8 comparisons based on the trials included: parenteral ketorolac versus phenothiazines (prochlorperazine, chlorpromazine), dopamine antagonists (metoclopramide), serotonin agonist (sumatriptan), steroid (dexamethasone), sodium channel blocker (sodium valproate), caffeine, NSAID (diclofenac), and opioid (meperidine). Primary outcomes were pain intensity at 1 hour and recurrence of headache post-treatment.

There was a single trial each comparing ketorolac to sumatriptan, dexamethasone, sodium valproate, caffeine, and NSAIDs. Trials comparing ketorolac and meperidine were removed from the analysis, as opioids are no longer recommended for treatment of migraine headaches. There were no trials included that compared ketorolac used in combination with other therapies for acute migraine.

Authors concluded that ketorolac had similar efficacy in treating acute migraine headache as phenothiazines: mean difference in pain intensity 0.09 (95%CI -0.45 to 0.64); metoclopramide 0.02 (95%CI -0.56 to 0.59). In single trials included in this meta-analysis, the authors also found that ketorolac was more effective in controlling migraine headaches than sodium valproate, dexamethasone, and nasal sumatriptan.

Overall, due to the paucity of trials included and the small sample sizes in the single trials, I don’t see any practice changing or confirming data in this meta-analysis. I will continue to use parenteral ketorolac as part of my initial multi-modal migraine cocktail in patients who do not have a contraindication to its use.

Efficacy of ketorolac in the treatment of acute migraine attack: A systematic review and meta-analysis. Acad Emerg Med. 2022 Sep;29(9):1118-1131. doi: 10.1111/acem.14457. Epub 2022 Mar 10.

What are your thoughts?