Ketorolac for Acute Migraine in Children

Efficacy and Administration

Intravenous ketorolac is commonly used for treating migraine headaches in children, though it's generally reserved for severe migraines 1, 2
Ketorolac has a relatively rapid onset of action and duration of approximately six hours 1, 2
Unlike chronic use of other analgesics, ketorolac is unlikely to cause rebound headaches when used for acute treatment 2

The American Academy of Neurology recommends ibuprofen as first-line medication for acute migraine in children 3
For moderate-severe migraines, consider ketorolac IV (0.5 mg/kg, maximum 30 mg) when oral medications are ineffective or not tolerated 1, 2
For adolescents, consider triptans (sumatriptan/naproxen oral, zolmitriptan nasal, sumatriptan nasal, rizatriptan ODT, or almotriptan oral) 4, 5, 3

Ketorolac is contraindicated in patients with aspirin/NSAID-induced asthma, pregnancy, and cerebrovascular hemorrhage 1
Potential adverse effects include edema, drowsiness, dizziness, gastrointestinal upset, and increased diaphoresis 1
Limit treatment duration to no more than five days 1

For patients with accompanying nausea or vomiting, consider adding an antiemetic such as metoclopramide or prochlorperazine 2

The American College of Physicians recommends using NSAIDs, including ketorolac, as first-line therapy for moderate to severe migraine, and CGRP antagonists like ubrogepant for patients who do not tolerate or have inadequate response to NSAIDs or triptans 6, 7, 8
Ketorolac, an NSAID, does not affect the CGRP receptor pathway that ubrogepant targets, and its use is supported by guidelines for acute migraine treatment 9

Patients taking ubrogepant at home for a migraine attack may present to an emergency department where ketorolac IV is administered for persistent severe pain, and guidelines suggest using ketorolac first, especially IV in acute care settings, and then taking ubrogepant if pain persists after 2 hours 6
The American College of Physicians suggests monitoring for NSAID-related adverse effects, including gastrointestinal upset, renal toxicity, and bleeding risk, when using ketorolac, and limiting treatment duration to no more than 5 days 9

The American College of Physicians recommends avoiding ketorolac in patients with aspirin/NSAID-induced asthma, pregnancy, active peptic ulcer disease, or significant renal impairment, and being aware of medication overuse headache risk with frequent use of acute migraine treatments 9, 6