New Research Explores Migraine and Opioids
Sait Ashina, MD, FAHS, and Richard Lipton, MD, FAHS, discuss their research on migraine and opioids
Richard Lipton, MD, FAHS, director of the Montefiore Headache Center at the Albert Einstein College of Medicine, and Sait Ashina, MD, FAHS, director of the Comprehensive Headache Center at Beth Israel Deaconess Medical Center, Harvard Medical School, were co-authors on the Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME) to Advance Understanding of Burden, Impact and Epidemiology of Migraine. This new research revealed new information about how providers use opioids to treat migraine disease in a range of acute care settings.
Migraine research and opioids
“We’ve been very concerned about the use of opioids broadly as a society,” Lipton says. “To a surprising degree, opioids are used for migraine.”
Recent studies have shown that of people with migraine who take acute prescription medications, more than a third keep opioids on hand to relieve their attacks. “It turns out men are more likely than women to get opioids, people who are obese are more likely to get opioids than people who are thin, and people who go to the emergency room for migraine are more likely to get opioids than people who don’t use the emergency room.”
However, opioids are a problematic treatment. “There’s good evidence from longitudinal studies that the more frequently you take opioids to relieve your migraine, the more likely you are to progress,” Lipton says. “There’s also evidence that treating with opioids makes other acute migraine medicines less effective. The high rates of opioid use among people with migraine is a problem that we need to work on solving.”
Lipton says that opioids make the nervous system more active and sensitized so that stimuli becomes painful where it ordinarily wouldn’t be. “And when that happens, the drugs that we normally use to treat migraine become less effective.” Not only are opioids less effective than migraine-relieving medications, he says, “their frequent use makes headaches come more often. And the third problem is that they may make other generally more effective acute medications less [so.]”
When opioids are appropriate
Narcotics should be the last solution for migraine, says Lipton. “In people who can’t tolerate or don’t respond to what are first-line options, opioids are occasionally useful.”
But instead, he says providers should coach migraine patients on managing symptoms so they don’t need to go to the emergency room, where opioids are more frequently prescribed.
“In many ways, I regard needing to go to an emergency room for migraine as a failure to plan or a medical failure. When that happens, I think long and hard about how to prevent future emergency visits. And really, the reasons are when you have a migraine, you’re sensitive to light, you’re sensitive to sound, you’re sensitive to odors,” he says. “Emergency rooms are not very comfortable places to be. It’s really worth thinking about how to keep people out of the emergency room if possible and how to manage them without opioids.”
Lessons learned from OVERCOME
Lipton and Ashina helped lead the OVERCOME study, initiated by Eli Lilly and Company. The goal of this web-based survey is to look at migraine burden and evaluate the obstacles to treating migraine appropriately.
“We are also looking at the stigma associated with migraine, and how that affects the individuals with this disabling condition,” says Ashina. “We also want to see how novel therapeutics, which are being introduced to the market, are going to affect migraine care.”
The study assessed 21,000 eligible participants with validated measures for psychiatric and pain comorbidities, headache-related disability, and former opioid use.
“The idea is that we take a snapshot on who has migraine and how people are getting treated, who’s getting diagnosed, what happens to people when they’re diagnosed, and why people don’t get diagnosed,” says Lipton. “In many ways, OVERCOME is the latest snapshot, and we can string those snapshots together to make a kind of movie to tell us how we’re doing in caring for people with migraine.”
Informative results
The study revealed that migraine is very stable in its prevalence in the US population. At the same time, more people than ever are going to the doctor and when they do, they’re far more likely to receive a diagnosis. It also showed that approximately 19% of the overall migraine population are current opioid users.
Additionally, says Ashina, “When we looked at the subgroup of patients with four or more migraine headache days per month, we found that individuals who used opioids are more likely to have pain comorbidities, for example, fibromyalgia, osteoarthritis, chronic back pain, chronic neck pain.”
These patients are also more likely to have psychiatric comorbidities such as anxiety and depression, as well as 15 or more migraine headache days per month. They are also more likely to have moderate to severe disability associated with their headaches. Ashina says that individuals with younger age and psychiatric comorbidities can be at a higher risk for opioid dependence. “An average migraine patient is a young person and can have anxiety and depression; previous studies have shown that there are higher rates of anxiety and depression in patients with migraine.”
Implications for providers and next steps
The American opioid crisis affects the country at the economical level, individual level, and societal level. Ashina says, “Seeing that rising numbers of opioids for migraine treatment in our study is concerning. Therefore, we need to emphasize more migraine-specific or more conventional treatments for migraine. How can we do that? We can educate physicians, the public, and patients about the available non-opioid treatments and the risks associated with opioids.”
Additionally, he also says the field needs more research to understand why people with migraine are using opioids. “We need to educate both patients and healthcare providers about migraine and about the available treatments. Future research should focus on additional risk factors for opioid use in patients with migraine, including associated migraine symptoms, use of headache abortive medications and preventive medications.”
Headache®: The Journal of Head and Face Pain is the official journal of the American Headache Society. AHS frequently reviews published research and provides commentary on the work being done to help advance the understanding of headache and face pain. For more analysis on studies published in Headache®, visit the AHS News page.