Q. Are opioids (narcotics) safe for migraine treatment?
Migraine has been views as a pain problem by many patients and health professionals in the past. Yet most migraineurs will acknowledge that pain is only one piece of the puzzle. Symptoms that accompany a migraine attack are just as intolerable as the head pain.
Viewing migraine merely as a pain problem leads to unintended consequences, namely promoting the use of painkiller medications as treatment—particularly narcotic drugs (such as opioids). While narcotics can be effective at relieving pain, their ability to eliminate associated symptoms and return patients to normal function is not well proven. Further, narcotics commonly cause drowsiness, which diminishes a person’s capacity to perform daily work or household activities. Thus, these medications may not be the ideal migraine treatment option.
Other research concludes that overuse of narcotics can cause episodic migraine to transform into a pattern of daily or near-daily headache. The American Academy of Neurology 2012 “Guidelines on Treating Migraine” state that opioids “may play a significant role in headache progression and patterns.”
Additionally, clinicians and patients often have concerns that the use of narcotic drugs could result in patterns of medication consumption best described as dependence or abuse. As a result, the use of narcotics for migraine remains controversial—yet, these drugs continue to be used widely.
Recent information from the American Migraine Prevalence and Prevention Study explored how narcotic medications are prescribed and consumed. Researchers sent questionnaires to 120,000 households across the United States. Information from a group of about 6,000 migraine respondents was analyzed. The results showed:
- About 30 percent of migraineurs had been prescribed a narcotic drug in the past four years, and 16 percent of those had been prescribed a narcotic medication at the time of the survey.
- Among individuals currently taking narcotics, about 67 percent used one narcotic agent, 20 percent used two agents, and roughly 10 percent used three narcotics.
- Nearly 20 percent of patients currently taking opioids could meet the clinical definition of dependence.
- Patients using narcotics were more likely to be unemployed, unmarried and have a lower household income when compared to individuals not using narcotics.
- Narcotic use was higher among women than men, and the average woman was approximately 50 years old.
Patterns of non-narcotic medication use were explored. In comparison to individuals not using narcotics, the annual rate of visiting a doctor’s office was three times higher for people currently or previously prescribed narcotics. The number of headache days per month was lowest among those not using narcotics (three days) and highest among narcotic dependent patients (nine days). Further, the emergency room visitation rate was four times higher for prior narcotic users, five times higher for current users and 24 times higher among dependent patients.
Whether narcotic use is a sign or cause of increased migraine severity remains an unanswered question. Until research is conclusive, narcotics should be reserved for situations when migraine-specific drugs or non-narcotic pain medications are ineffective, cause significant adverse effects or are contraindicated. In situations where prescribing a narcotic may be appropriate, patients’ overall ability to function should be regularly monitored as should their use of other medications and worsening of other illnesses.
Richard Wenzel, PharmD, Staff Pharmacologist, Diamond Headache Unit, St. Joseph Hospital, Chicago, Ill.
