Ketorolac is effective for headaches, particularly migraines. In clinical trials, a nasal spray formulation provided two-hour pain relief in about 73% of migraine patients, and nearly half experienced complete pain freedom. The American Headache Society includes intravenous ketorolac among the treatments emergency departments should offer for migraine attacks.
How Well It Works for Migraines
A randomized, double-blind crossover study from Johns Hopkins compared ketorolac nasal spray, sumatriptan nasal spray, and placebo for moderate to severe migraine attacks. Both active treatments significantly outperformed placebo, but the results for ketorolac were striking: 72.5% of patients had pain relief at two hours (compared to 38.3% on placebo), and 43.1% were completely pain-free. Sumatriptan, one of the most widely used migraine-specific medications, performed similarly at 69.4% relief and 36.7% pain freedom.
Where ketorolac pulled ahead was at the 24-hour mark. About 49% of patients on ketorolac had sustained pain relief over 24 hours, versus 31% on sumatriptan and 20% on placebo. And for sustained pain freedom over 24 hours, ketorolac was the only treatment that beat placebo (35.3% vs. 12.2%). Sumatriptan fell short of statistical significance at that time point. This matters because migraine recurrence is a common frustration, and ketorolac appears to hold up better over the full day.
How It Compares to Other ER Treatments
In the emergency department, ketorolac is typically given intravenously. A meta-analysis comparing IV ketorolac to IV metoclopramide (an anti-nausea medication commonly used for ER migraines) found that metoclopramide actually had a slight edge for short-term headache relief. For sustained relief and overall pain intensity, the two were essentially equivalent. Both the American Headache Society and the Canadian Headache Society recommend metoclopramide as a first-line option, with ketorolac as another strong choice. The AHS gives IV ketorolac a Level B recommendation, meaning it “should be offered” for migraines requiring parenteral therapy in emergency settings.
In practice, emergency physicians often combine ketorolac with other medications rather than using it alone. It works through a different mechanism than migraine-specific drugs like triptans or anti-nausea medications, so it can complement them. Ketorolac is a powerful anti-inflammatory painkiller in the same family as ibuprofen and naproxen, but considerably stronger.
Different Ways It’s Given
Ketorolac comes in three forms: intravenous, intramuscular injection, and a nasal spray (sold as Sprix). The IV and IM versions are what you’ll get in an emergency department or urgent care. Standard dosing is 30 mg IV or up to 60 mg IM for adults under 65.
The nasal spray is the only form you can use at home, dosed as one spray in each nostril (31.5 mg total) every six to eight hours. It was the formulation used in the Johns Hopkins migraine study, and it performed well. For adults 65 and older, those with kidney problems, or those weighing under 110 pounds, the dose is halved to a single spray in one nostril. Each bottle is single-day use only and must be discarded after 24 hours, even if liquid remains.
One important point: despite ketorolac’s reputation as a more potent option than over-the-counter painkillers, research consistently shows that oral ibuprofen provides similar pain relief to injected ketorolac for many types of pain. Multiple randomized trials found no significant difference in pain scores between the two at any time point. This doesn’t diminish ketorolac’s usefulness for migraines specifically, but if you’re comparing it to popping an ibuprofen at home, the gap may be smaller than you’d expect for mild to moderate headaches.
The Five-Day Limit
Ketorolac carries a strict maximum of five days of use, regardless of the form. This is a boxed warning on the label, the FDA’s most serious safety alert. The reason is gastrointestinal bleeding. Post-marketing data from roughly 10,000 patients showed that treatment beyond five days more than doubled the rate of serious GI bleeding compared to opioid painkillers. For clinically significant bleeding events, the risk nearly tripled.
When treatment stays within five days and dosing stays at or below 105 mg per day in adults under 65, the bleeding risk is not elevated compared to other pain medications. The risk climbs steeply with higher doses and older age. In patients under 65 with no history of stomach ulcers or GI bleeding, doses at or below 60 mg per day carry a 0.4% risk of serious GI bleeding. Push that above 120 mg daily, and the rate jumps to 4.6%. For patients 65 and older with a history of GI problems, high doses carry a GI bleeding risk as high as 25%.
Who Should Avoid It
Ketorolac is not appropriate for everyone with a headache. People with kidney disease, severe liver disease, or a history of stomach ulcers or GI bleeding face significantly higher risks. It can worsen asthma, high blood pressure, and heart disease. Anyone with a bleeding disorder or history of brain hemorrhage should not take it, as ketorolac interferes with blood clotting.
Diabetes, lupus, alcohol use disorder, and fluid retention (edema) also increase the chance of serious side effects. If you’re already taking another anti-inflammatory painkiller like ibuprofen, naproxen, or aspirin, combining them with ketorolac raises bleeding risk further. Because of these restrictions and the five-day limit, ketorolac works best as a short-term rescue treatment for severe or resistant headaches rather than a go-to for everyday headache management.
Where Ketorolac Fits In
For people who get occasional severe migraines and don’t respond well to triptans, or who can’t take triptans due to cardiovascular issues, ketorolac nasal spray offers a legitimate alternative with comparable two-hour efficacy and potentially better 24-hour staying power. In the ER, it’s one of the standard tools for breaking a migraine that’s brought someone in for treatment.
For tension headaches or mild to moderate pain, ketorolac is likely more firepower than you need. Over-the-counter ibuprofen provides similar relief for those situations without the tighter safety restrictions. Ketorolac’s real value is for the severe headache that isn’t budging, used infrequently and for no more than five days at a time.