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In the pediatric patient diagnosed with refractory migraine is ketorolac an effective treatment?

Plain language summary from the office of evidence based practice: 
Based on very low quality evidence, the Migraine in the ED CPG Teams makes a Conditional Recommendationto use ketorolac or valproic acid as the second line treatment, with the potential to use valproic acid if needed based on prior NSAID exposure. Friedman et al. (2014) reported there was no difference when comparing ketorolac vs. valproic acid for pain relief at 2 hours. However, the use of rescue medications was lower in the group who received ketorolac. Although ketorolac appears to have greater efficacy, it should not be used if NSAIDs were recently taken*. If valproic acid is used, pregnancy testing in females must be negative.

Literature synthesis: Although the included studies are methodologically strong, they are only three studies that include a small number of subjects (see Figure 1). Meta- analysis cannot be performed.

  • Friedman et al (2014) compared 30 mG IV ketorolac to 1 gram IV valproic acid and found there was:

    • No difference in pain relief at two hours after medication administration. OR = 1.91, 95% CI [0.96, 3.79], p= 0.06.

    • Significantly less use of rescue medications when ketorolac was administered OR= 0.48, 95% CI [0.28, 0.83], p= 0.009.

  • Brousseau, Duffy, Anderson, & Linakis (2004) compared 0.5 mG/kg; (maximum 30 mG) IV ketorolac to 0.15 mG/kg IV prochlorperazine (maximum 10 mG). The study was stopped early due to the overwhelming benefit of pain relief within two hours in the group treated with prochlorperazine. (OR= 4.55, 95% CI [1.37. 15.11], p= 0.01. The odds of having pain relief if treated with prochlorperazine was 4.5 times greater than if treated with ketorolac.

  • Meredith, Wait, & Brewer (2003) compared IV ketorolac to nasal sumatriptan and reported pain scores within two hours of treatment. The group treated with IV ketorolac had significantly lower pain scores than subjects treated with nasal sumatriptan MD = -40.76, [-60.35, -21.16].

*Caution: Ketorolac should not be used if NSAIDs were taken within the following timeframes: 

  • ibuprofen < 6 hours prior administration

  • naproxen  sodium < 12 hours prior administration

The dose of ketorolac is 0.5 mG/kg IV (max 30mG) and 1 mG/kg IM (max 60 mG).

See Appendix G for the full Critically Appraised Topic (CAT).

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.