100 Migraine Drugs, A to Z: ketorolac
Ketorolac (Toradol) is one of many nonsteroidal anti-inflammatory (NSAID) pain medications used to treat migraine headaches. In a tablet form it is no more effective than ibuprofen, naproxen or any other NSAID, but has more side effects and its use is limited to 5 days. On the other hand, ketorolac in an injection is a unique and very useful drug. It provides pain relief comparable to that of opioid (narcotic) drugs without the side effects or addiction potential of those drugs.
Intravenous ketorolac has been proven to be an effective drug for the treatment of severe migraine attacks. A study done by Dr. B. Friedman and his colleagues at the emergency department of the Montefiore Medical Center in the Bronx compared intravenous infusion of 30 mg of ketorolac with an infusion of 10 mg of metoclopramide (Reglan) and 1,000 mg of valproate (Depacon). There were over 100 patients in each group, making this a highly reliable study. Ketorolac and metoclopramide were more effective than valproate, but metoclopramide caused severe restlessness in 6 (6%) of patients. This is a well known side effect of metoclopramide and a similar drug, prochlorperazine (Compazine). This side effect is extremely unpleasant, but can be relieved by diphenhydramine (Benadryl).
Intramuscular injection of 60 mg of ketorolac was compared to intravenous infusion of 25 mg of chlorpromazine (Thorazine) and they were found to be equally effective. Just like prochlorperazine, chlorpromazine carries a risk of restlessness, as well as involuntary movements and sedation. These two drugs belong to the phenothiazine family of drugs, which are also used for severe nausea and vomiting, and psychiatric disorders.
A review of eight published trials of ketorolac found it to be more effective than meperidine (Demerol) and sumatriptan and a little less effective than metoclopramide, chlorpromazine and prochlorperazine. However, ketorolac lacks the addiction potential and the risk of severe restlessness, sedation, and involuntary movements.
We given intravenous ketorolac to our patients whose migraine has not responded to an injection of sumatriptan or oral triptans, although we almost always give an infusion of magnesium before or along with ketorolac.
Yes, because they are safer and usually more effective.
Are ketorolac injections preferable over prednisone?
I’m very familiar with this drug and how it’s used. My daughter is 8 and was diagnosed with chronic migrainosus with aura at 4 1/2. She’s on preventative meds, we have frova on hand, oral version of the migraine cocktail for pain scale 1-4 and experience has taught us above that requires and visit to the ER for the IV version. The IV cocktail works far more efficiently than the oral, and your post here confirms my suspicions why. We have been struggling to control her migraines and IV toradol, along with the Reglan and Benedryl, break it 99.999999% of the time.
I am not skeptical about your results because every person responds differently and I have also seen a few patients for whom ketorolac tablets worked better than any other NSAID. I do prescribe it for those rare patients, but in a very limited amounts.
Thank you for posting about Toradol. Unlike some migraine patients, I find the oral form of Toradol to be much more effective than over-the-counter NSAIDs, which do not help me at all. When I have a headache that does not completely respond to Imitrex or Zomig, I take 20 mg of Toradol and that usually brings me complete relief. Sometimes the pain returns several hours later, but often it does not. And I don’t seem to suffer any side effects. My neurologist is skeptical about Toradol’s effectiveness, but I am a true believer!
Yes, intravenous ketorolac is more effective and works faster, so we always give it intravenously in the office. However, patients cannot give it to themselves intravenously, only intramuscularly.
Is there a difference between intravenous vs injectable Toradol to stop a migraine? I have only been offered the shot. Thank you
Yes, we prescribe injectable ketorolac to some of our patients and they self-inject it intramuscularly. In addition to the prescription for ketorolac (usually, 10 vials with 30mg in each), you need a prescription for syringes. As mentioned in the post, there is no point in taking oral ketorolac as it causes more GI side effects and is no better than ibuprofen. Indomethacin is stronger than over-the-counter NSAIDs and the dose can be up to 75 mg. However, while it is much stronger than oral ketorolac, it also carries a high risk of GI side effects.
Is it possible to get Rx for injectable toradol at home? Or is it only available in urgent care/ER situations? My local urgent care is great & treats me with: IV Benadryl, reglan & either/or toradol, steroid. I have Rx for 10mg toradol & 25mg indomethacin so sometimes I can’t get the injectable toradol if I’ve already had a NSAID recent to my admission.