Opioids in Headache
Opioids will continue to be used for acute pain of all types including migraine and other headaches. There are generally better alternatives, such as DHE, non-steroidal anti-inflammatory drugs, and neuroleptic anti-emetics. However, data about relative effectiveness of opioids and other analgesic/abortive medications are by no means complete as different members of the opioid class have different properties and potencies, and exhaustive comparative trials have not been done. Opioids have numerous adverse effects, some life-threatening. There is high risk for tolerance, dependency, and addiction with significant effects on patients, families, and communities. And opioid use seems to make migraines subsequently more frequent and more difficult to treat. However, there are patients for whom opioids on occasion are optimal acute treatments, for example, patients who have contraindications to ergot-type medications because of cardiovascular or cerebrovascular conditions, patients who should not receive neuroleptic medications because of QT prolongation or other contraindications, pregnant women, and patients who cannot tolerate or fail to respond to all other categories of acute medications. In these situations, both clinician and patient should thoroughly understand the pitfalls in using opioids and make a conscious decision to use them sparingly. This will also apply to cases of secondary head pain expected to be of a time-limited course.
As for prophylaxis in patients with refractory CM, regular preventive dosing can seem better than the nightmare of daily or near daily severe pain. And certainly, there are a handful of patients who seem to flourish with a carefully controlled regimen of methadone or long-acting morphine preparation. But in the experience of most headache medicine specialists, these patients are very few in number, and this observation is borne out by the longitudinal studies. Moreover, the recent trend in overprescribing opioids for chronic non-terminal pain has led to serious individual and societal consequences that must now be addressed conscientiously. On the other hand, this approach, if done in a careful way by skilled practitioners, can be viable for selected cases.
Conclusions
Opioids will continue to be used for acute pain of all types including migraine and other headaches. There are generally better alternatives, such as DHE, non-steroidal anti-inflammatory drugs, and neuroleptic anti-emetics. However, data about relative effectiveness of opioids and other analgesic/abortive medications are by no means complete as different members of the opioid class have different properties and potencies, and exhaustive comparative trials have not been done. Opioids have numerous adverse effects, some life-threatening. There is high risk for tolerance, dependency, and addiction with significant effects on patients, families, and communities. And opioid use seems to make migraines subsequently more frequent and more difficult to treat. However, there are patients for whom opioids on occasion are optimal acute treatments, for example, patients who have contraindications to ergot-type medications because of cardiovascular or cerebrovascular conditions, patients who should not receive neuroleptic medications because of QT prolongation or other contraindications, pregnant women, and patients who cannot tolerate or fail to respond to all other categories of acute medications. In these situations, both clinician and patient should thoroughly understand the pitfalls in using opioids and make a conscious decision to use them sparingly. This will also apply to cases of secondary head pain expected to be of a time-limited course.
As for prophylaxis in patients with refractory CM, regular preventive dosing can seem better than the nightmare of daily or near daily severe pain. And certainly, there are a handful of patients who seem to flourish with a carefully controlled regimen of methadone or long-acting morphine preparation. But in the experience of most headache medicine specialists, these patients are very few in number, and this observation is borne out by the longitudinal studies. Moreover, the recent trend in overprescribing opioids for chronic non-terminal pain has led to serious individual and societal consequences that must now be addressed conscientiously. On the other hand, this approach, if done in a careful way by skilled practitioners, can be viable for selected cases.