Opioids have utility in migraine treatment, but they are often overprescribed, which may be hurting patients. Stephen Silberstein, MD, FAHS says a lack of physician education is to blame
For certain groups of patients with migraine, like the elderly and pregnant women who often avoid triptans or nonsteroidal anti-inflammatory drugs (NSAIDs), opioid medications could potentially be used for occasional pain management. But in today’s treatment landscape where migraine-specific medications that target the source of a patient’s symptoms are effective and available, opioids continue to be prescribed at unnecessarily high rates, a practice that can have devastating effects on individuals, according to Stephen Silberstein, MD, FAAN, FACP, FAHS, director of the Headache Center at Jefferson University Hospital.
Migraine treatment in emergency departments
Opioids continue to be used in over 50 percent of emergency department migraine visits, according to a 2014 study published in Headache, even though medications that directly target migraine symptoms, like triptans, are also available, and may be more effective for many. Migraine patients are routinely prescribed OxyContin, Vicodin, Percocet and other opioid-based medications in an attempt to treat their headache pain, which some specialists say strays far from the best practices applied within the headache medicine field.
“The problem we have is that many physicians treat the symptoms, and not the disease,” Silberstein said. “So if you have a pain of any type, they’re treated with an opioid,” even though “evidence strongly suggests that opioids are not as effective as medicine like triptans.”
Opioids and migraine progression
The use of opioids in patients with migraine carries a high risk of medication overuse headache (MOH). Opioids can cause MOH when used more than ten times per month: if a high-frequency episodic or chronic migraine patient relies on opioids for pain relief, they can easily become dependent, leading to a complicated detoxification process that may aggravate their symptoms.
“Sometimes patients have to be admitted for detoxification,” Silberstein said. “Other times, they have to be slowly tapered off and carefully monitored, realizing that during the taper, their headaches could get worse.”
Routine use of opioids for migraine treatment often leads to more frequent and severe headaches, and detoxifying from opioid dependency isn’t always enough to undo that damage. For many patients, overuse of opioids can trigger the transition from episodic migraine to chronic migraine. That’s why it is crucial to ensure that both simple analgesics and triptans are contraindicated before considering prescribing an opioid medication. These acute medications treat the source of the pain, not just the pain itself, and are less likely to induce migraine progression.
“I think the problem we have with the opioid crisis is people looking at symptoms and not the disease,” Silberstein said. “Why are patients getting opioids? They’re getting opioids because pain became the vital sign, and people were treating the symptom and not the disease. We need to focus on what’s causing the pain, and treat that, not simply giving a palliative treatment for the pain.”
Opioids’ role in migraine treatment
The general criterion on opioid use for migraine is as a last resort. “I’m not saying opioids are always wrong and always evil,” Silberstein said, “But in patients that take opioid for the treatment of migraine, they frequently wind up with more frequent and more severe headaches, and the worst part is when you stop them, their headaches don’t always get better.”
Being proactive in your treatment regime can play a role in successful pain relief. Silberstein recommends patients develop an emergency department plan with their doctors so they are not given opioids unnecessarily or misjudged as “drug-seeking” and denied necessary care. A written note advising acute treatments like triptans or NSAIDs as the first line of defense can help bridge the communication gap between headache specialists and emergency department personnel.
“Good care gives good results,” Silberstein said. For many migraine patients, “opiates are a shortcut that results in bad care.”
Are there any circumstances where opioids should be used?
Evidence strongly suggests that opioids are not as effective as acute medications like triptans, but for certain patient groups they offer a necessary alternative option for pain relief. Patients with a history of cardiovascular disease are unable to take triptans or NSAIDs due to their side effects: for this reason, triptans and NSAIDs are contraindicated for the elderly due to their increased risk for cardiovascular disease. In those cases, opioids may be the only treatment option for relief from a severe headache.
Pregnant women who experience frequent migraine attacks will often abstain from acute medication during pregnancy, and may be prescribed opioids under the supervision of their physician to provide occasional symptom relief. Opioid use in pregnant women must be closely monitored, and infrequent, due to the risk of passing on an opioid dependency to their unborn child.
Stephen Silberstein, MD, FAHS is a member and past president of the American Headache Society, a professional society for doctors and other health care workers who specialize in studying and treating headache and migraine. The Society’s objectives are to promote the exchange of information and ideas concerning the causes and treatments of headache and related painful disorders, and to share and advance the work of its members. Learn more about the American Headache Society’s work and find out how you can become a member today.
Minen, M. T., Tanev, K. and Friedman, B. W. (2014), Evaluation and Treatment of Migraine in the Emergency Department: A Review. Headache: The Journal of Head and Face Pain, 54: 1131–1145. doi:10.1111/head.12399