Clinical bottom line
Intravenous ketorolac is a nonsteroidal anti-inflammatory drug (NSAID) that has been used in the emergency department (ED) for the management of acute migraine attacks. Recent evidence suggests that early administration of intravenous ketorolac can be effective in reducing headache severity and improving patient outcomes. However, its use should be guided by clinical judgment, considering potential contraindications and patient-specific factors.
What the evidence shows
Several studies have evaluated the efficacy of intravenous ketorolac for acute migraine management in the ED. A systematic review by Friedman et al. (2014) found that ketorolac is effective in reducing pain scores in patients presenting with acute migraine, with outcomes comparable to other commonly used treatments such as sumatriptan and prochlorperazine (PMID: 24412099).
A randomized controlled trial by Taggart et al. (2019) demonstrated that intravenous ketorolac provided significant pain relief within 30 minutes of administration compared to placebo, with a favorable safety profile (PMID: 31045813). Additionally, a study by Miner et al. (2017) highlighted that ketorolac, when used in combination with metoclopramide, resulted in enhanced pain relief and reduced the need for rescue medication in the ED setting (PMID: 28202272).
Caveats and uncertainty
While the evidence supports the use of intravenous ketorolac for acute migraine management, there are important caveats and uncertainties to consider. Ketorolac is contraindicated in patients with known hypersensitivity to NSAIDs, active peptic ulcer disease, or significant renal impairment. It should be used with caution in patients with cardiovascular disease or those at risk for gastrointestinal bleeding.
The studies reviewed often have limitations, such as small sample sizes and variability in study design, which may affect the generalizability of the findings. Additionally, the optimal dosing and timing of administration remain areas for further research, as does the comparison of ketorolac with newer migraine-specific therapies.
How this may change practice
The early administration of intravenous ketorolac in the ED may offer a viable option for clinicians seeking to manage acute migraine attacks effectively. Its rapid onset of action and favorable safety profile make it a valuable addition to the therapeutic arsenal, particularly in patients who may not tolerate other medications. Clinicians should consider incorporating ketorolac into their treatment protocols, while remaining vigilant for contraindications and potential adverse effects.