Intranasal ketorolac versus intravenous ketorolac for treatment of migraine headaches in children: A randomized clinical trial

Daniel S Tsze, Tamar R Lubell, Robert C Carter, Lauren S Chernick, Kerrin C DePeter, Son H McLaren, Maria Y Kwok, Cindy G Roskind, Ariana E Gonzalez, Weijia Fan, Shannon E Babineau, Benjamin W Friedman, Peter S Dayan, Daniel S Tsze, Tamar R Lubell, Robert C Carter, Lauren S Chernick, Kerrin C DePeter, Son H McLaren, Maria Y Kwok, Cindy G Roskind, Ariana E Gonzalez, Weijia Fan, Shannon E Babineau, Benjamin W Friedman, Peter S Dayan

Abstract

Background: Intravenous ketorolac is commonly used for treating migraine headaches in children. However, the prerequisite placement of an intravenous line can be technically challenging, time-consuming, and associated with pain and distress. Intranasal ketorolac may be an effective alternative that is needle-free and easier to administer. We aimed to determine whether intranasal ketorolac is non-inferior to intravenous ketorolac for reducing pain in children with migraine headaches.

Methods: We conducted a randomized double-blind non-inferiority clinical trial. Children aged 8-17 years with migraine headaches, moderate to severe pain, and requiring parenteral analgesics received intranasal ketorolac (1 mg/kg) or intravenous ketorolac (0.5 mg/kg). Primary outcome was reduction in pain at 60 min after administration measured using the Faces Pain Scale-Revised (scored 0-10). Non-inferiority margin was 2/10. Secondary outcomes included time to onset of clinically meaningful decrease in pain; ancillary emergency department outcomes (e.g. receipt of rescue medications, headache relief, headache freedom, percentage improvement); 24-h follow-up outcomes; functional disability; and adverse events.

Results: Fifty-nine children were enrolled. We analyzed 27 children who received intranasal ketorolac and 29 who received intravenous ketorolac. The difference in mean pain reduction at 60 min between groups was 0.2 (95% CI -0.9, 1.3), with the upper limit of the 95% CI being less than the non-inferiority margin. There were no statistical differences between groups for secondary outcomes.

Conclusions: Intranasal ketorolac was non-inferior to intravenous ketorolac for reducing migraine headache pain in the emergency department.

© 2021 Society for Academic Emergency Medicine.

References

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