The use of opioids in patients with migraine is common but carries a high degree of risk. Presenters at the American Headache Society 61st Annual Scientific Meeting, held July 11–14 in Philadelphia, addressed various aspects of this growing problem.
More acute medication overuse
Todd Schwedt, MD, Associate Professor of Neurology at the Mayo Clinic in Phoenix, AZ, participated in the MAST Study of adults with migraine, in which respondents with acute medication overuse (AMO) were significantly more likely to be taking triptans, opioids, barbiturates, and ergot alkaloids and significantly less likely to be taking NSAIDs than those not overusing medications. AMO was associated with higher symptom severity scores, pain intensity, and rates of cutaneous allodynia.
Earlier, Dr Schwedt and coauthors advised encouraging patients with migraine to obtain migraine pain treatment early and avoid overuse of medications. They recommended considering infrequent use of opioids or acetaminophen in combination with codeine or tramadol as part of the “back‐up plan” when the initial treatment does not provide meaningful and sustained benefits.
Increases in opioid abuse and opioid-related deaths
Sait Ashina, MD, Assistant Professor of Neurology, Beth Israel Deaconess Medical Center, Brookline, MA, coauthored a commentary, “Pain: What We Have Achieved in the Past 25 Years,” that described advances in understanding of pain and new agents for the treatment of acute and chronic pain. Well-selected patients have benefited from opioids, it was noted, but a rise in the prescription of opioids has resulted in increases in prescription opioid abuse and opioid-related deaths. Clinicians are becoming better educated on how to manage pain with opioids and monitor for and treat addiction, and abuse-deterrent opioid formulations are becoming more available.
In another commentary, Dr Ashina suggested that the use of opioids in the treatment of headache has been limited, especially because of the availability of conventional therapies for migraine and concerns about overuse and possible adverse effects, but opioids use can result in headache reduction and functional improvement in some patients.
Reducing unwarranted opioid exposure in youth
Jennifer Bickel, MD, Neurologist and Medical Director of the Headache Program at Children's Mercy Hospital and Clinics in Kansas City, MO, and coauthors recently conducted a study to evaluate opioids used for treating migraine in adolescents and young adults in emergency care settings. The likelihood of being treated with opioids was significantly higher for patients who were older, female, white, and seen by a surgeon and who had longer and earlier encounters. Higher rates of encounters involving opioids were associated with smaller sites that had relatively higher proportions of commercially insured patients. The authors suggested that the findings “may be helpful for benchmarking and informing quality improvement efforts aimed at reducing unwarranted opioid exposure in youth.”
1. Global Leaders in Migraine Research to Convene at The American Headache Society 61st Annual Scientific Meeting [press release]. Mount Royal, NJ: American Headache Society. July 8, 2019. Accessed July 9, 2019.
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