Lastly, tramadol 100 mg IM yielded pain relief similar to diclofenac 75 mg IM. Headaches treated with opioids have a high rate of recurrence after the analgesic effect of
the opioid wears off. Opioids may, however, make the patient drowsy enough to sleep, which often terminates headaches. Side effects of opioids included sedation, dizziness, GI discomfort, Olaparib cell line nausea and vomiting, and akathisia (although the last occurs much less frequently than with the dopamine antagonists). Opiates/opioids often are used in treating patients with status migrainosus. In one study, however, patients in status became pain free after treatment with ketorolac and sumatriptan only if they had used no opiates/opioids whatsoever in the previous 6 months.22 This result reinforces the notion that opioids may exert a persistent pro-nociceptive effect – a “pain-memory state”– that prevents the reversal of central sensitization.4 KU-57788 mouse Along the same line, Ho et al found that rizatriptan was less effective as a migraine abortive if patients had recent exposure to opioids.40 As such, concern for creating opiate/opioid dependency in migraine patients may not be the most important reason for not recommending this class of drugs as first-line therapy. Even so, the habituation rate associated with the use of opioids for migraine treatment is estimated at 13 out of 1 million patients, and
ED staff rightfully are concerned at the prospect of contributing to an already established habituation or even true addiction, especially in patients with the latter who misrepresent themselves as having headaches.41,42 When one considers that the opioids studied were superior only to placebo and ketorolac 30 mg IM, the issue of their potential pro-nociceptive effect, abuse/addiction issues, and the evidence that the use of opioids appears to render relatively migraine-specific abortive medications less effective, it is recommended that opiates/opioids MCE not be used as first-line therapy for migraine pain in the ED or clinic. Ketorolac is a cyclooxygenase COX1/COX2 inhibitor that appears to be able to reverse both peripheral
sensitization by inhibiting the neuroinflammatory cascade in the meninges and central sensitization associated with cutaneous allodynia. Ketorolac effectively treated acute migraine in patients with cutaneous allodynia who did not respond to sumatriptan SQ. Ketorolac 30 mg IV or 60 mg IM is more efficacious than sumatriptan nasal spray and less efficacious than prochlorperazine or DHE plus metoclopramide but similar to meperidine plus promethazine or hydroxyzine. In the only study which included a placebo arm, an unusually high rate of pain relief was reported by the both the ketorolac and placebo groups. Halving its IM dose to 30 mg resulted in ketorolac being less efficacious in reducing pain than meperidine.