Severe migraines do not need narcotic pain drugs

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Patients who show up in the ER with severe migraines are often given narcotic drugs to control their pain, but new research suggests that a drug called ketorolac (Toradol) may be a better alternative to the habit-forming agents.

All of the patients in the study had allodynia, a hypersensitivity problem that occurs in about four out of five patients with migraines. With allodynia, touch and other stimuli that are normally not painful begin to cause pain. Once allodynia develops, triptans - the standard first-line drugs for migraines - are no longer effective. Thus, these patients often visit the ER for pain control.

Ketorolac is classified as a non-steroidal antiinflammatory drug or NSAID, the same group of drugs that includes aspirin and ibuprofen (Motrin, Advil). However, unlike many NSAIDs, ketorolac is readily available in a potent injectable form.

The results of the current study show that migraine sufferers can benefit from this intravenously administered NSAID and that narcotic pain relievers “should only be given as a last resort,” said lead author Dr. Rami Burstein, from Harvard Medical School in Boston.

“The only patients ketorolac did not work in were those who had been treated with (narcotics) in the past,” he noted.

Burstein is presenting his findings Saturday at the annual meeting of the American Headache Society in Philadelphia.

Burstein’s team assessed pain control in 14 patients who were given ketorolac 4 hours after migraine onset and in 14 patients who received a triptan drug 4 hours after headache onset followed by ketorolac 2 hours later.

Given alone, ketorolac resolved headache and allodynia in 9 of the 14 patients, the report indicates. The triptan plus ketorolac treatment worked in 10 of 14 patients, but no improvement occurred until after ketorolac was given.

As Burstein mentioned, all five non-responders in the ketorolac-only group and all four in the triptan/ketorolac group had a history of narcotic use for migraine pain control.

These findings have important implications because each year “800,000 Americans present to the ER for migraines that they can’t treat themselves,” Burstein said. “More than 400,000 of these patients get (narcotic pain relievers) as the first-line therapy. Our findings suggest that this doesn’t need to happen” - they can get significant relief from ketorolac instead.

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