In studies of adults, opioid use for migraine is high. In the Chronic Migraine Epidemiology and Outcomes (CAMEO) study, 36.3% of respondents were using opioids for migraine.4 Schwedt and colleagues4 described several factors associated with opioid use in the CAMEO respondents:
• Male sex
• Increasing body mass index
• Increasing monthly headache day frequency
• Increasing trigger points outside of the head, face, and neck
• Depression, anxiety, and cardiovascular comorbidity
• Emergency facility use during the past 6 months
For patients who were given a diagnosis of migraine or chronic migraine, there was a decreased likelihood of opioid use.4
The OVERCOME study evaluated the treatment of migraine in patients with 4 or more migraine headache days per month. The study concluded that a majority of people with 4 or more migraine headache days per month have seen a health care professional for headache; most have seen their PCP. PCPs prescribe triptans to 33% of these patients and opioids to 27%.9 Patients with migraine in this study who were seen by a neurologist or headache specialist received triptans at a lower rate (26% to 27%) than those seen by PCPs and received fewer opioids (11% to 12%).9 Patients seen by neurologists and headache specialists were more likely to be prescribed preventive medications.
Implications for clinicians
Epidemiology studies are useful to clinicians when treating patients because they highlight diagnosis and prescribing patterns, common trends within a disease, and unmet needs. For migraine, these studies all highlight that further education targeting primary care, hospitalists, and emergency physicians is needed to improve the quality of care provided to persons with migraine and help reduce the burden of opioid use. Opioids are well known to worsen migraine frequency and severity, causing opioid hyperalgesia and potentially contributing to central sensitization, both risk factors for transformation of migraine to chronic migraine.10,11 Targeted education on early diagnosis of migraine and appropriate acute treatment options for both outpatient and inpatient use may help reduce disability related to migraine.
1. World Health Organization. Headache disorders. 2016. https://www.who.int/news-room/fact-sheets/detail/headache-disorders. Accessed July 22, 2019.
2. Lipton RB. Patterns of diagnosis, consultation, and treatment of migraine in the US: results of the OVERCOME study. Presented at: American Headache Society 61st Annual Scientific Meeting; July 11-14, 2019; Philadelphia, PA.
3. Lipton RB, Reed ML, Munjal S, et al. One-year incidence of migraine in the US population: results from the Migraine in America Symptoms and Treatment (MAST) study. Headache. 2019;59:9.
4. Schwedt TJ, Lipton RB, Friedman BW, et al. Demographics, headache characteristics, and other factors associated with opioid use in people with migraine: results from the Chronic Migraine Epidemiology and Outcomes Study. Headache. 2019;59:6.
5. Ashina S, Foster SA, Nicholson RA, et al. Opioid use among people with migraine: results of the OVERCOME study. Headache. 2019;59:6.
6. Bickel J, Connelly M, Glynn EF, et al. Rates and predictors of using opioids in the emergency department to treat migraine in the adolescents and young adults. Headache. 2019;59:12.
7. Schwedt T, Munjal S, Reed ML, et al. Headache treatment patterns and co-morbid health burden associated with emergency department and urgent care use in people with migraine: survey results from Migraine in America Symptoms and Treatment study. Headache. 2019;59:17.
8. Platzbecker K. Incidence, consequences, and prevention of postoperative, pain-related hospital readmission in migraineurs. Presented at: American Headache Society 61st Annual Scientific Meeting; July 11-14, 2019; Philadelphia, PA.
9. Buse DC, Nicholson RA, Araujo AB, et al. Migraine care across the healthcare landscape in the United States among those with 4 or greater migraine headache days per month: results of the OVERCOME study. Headache. 2019;59:16.
10. Mitra S. Opioid induced hyperalgesia: pathophysiology and clinical implications. J Opioid Manag. 2018;4:123-130.
11. Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine. Pain. 2009;142:179-182.