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Recommended guidelines for opioid treatment

In this final installment of our series on opioid medications we will be exploring the guidelines recommended by leading headache experts. In case you’re just now joining in, please take a look at A balancing act – opioid use throughout history, Risks of long-term opioid treatment, and Migraine-specific opioid treatment to catch up.

Dr. John Rothrock explains that there is bias against prescribing opioids among headache specialists. Part of the trouble has been that until recently patients with Chronic Migraine have been excluded from clinical studies. Doctors are generally averse to using treatments not supported by a lot of research. His recommendation is that the use of short-acting opioid as a rescue treatment for severe migraine “would appear both sensible and medically appropriate” when compared to the options of either allowing the patient to suffer or referring the patient to the ER3.

The American Headache Society cautions the regular use of short-acting opioids as a migraine treatment, call them “a double-edged sword”. They remind doctors and patients that no one is immune to the addictive potential of opioids and makes recommendations for their safer use1.

  1. Opioid prescriptions from only one physician
  2. Filled at only one pharmacy
  3. Prescriptions should specify precisely how long the quantity is supposed to last
  4. Early refill requests should be discouraged
  5. Dose should be administered as soon as the headache reaches moderate to severe pain intensity
  6. Use the lowest effective dose
  7. Patient education to include:
    1. Patient responsibility to take as prescribed
    2. side effects versus allergic reaction
    3. limit use to a maximum of twice weekly
    4. increased risks
      1. reduced effectiveness if waiting too long to take a dose
      2. worsening migraine with overuse
      3. becoming less responsive to other acute migraine medications

A study conducted by Dr. Lawrence Robbins evaluated headache patients diagnosed with refractory chronic migraine who had been prescribed long-acting opioids between 2002 and 2007 after failing multiple preventive and abortive medicines. All of these patients had done well on short-acting opioids in the past. Comorbid conditions were considered to determine if their presence affected the risk for abuse. They took into account numerous factors, including the presence of mental illness, exercise, coping skills, employment, disability status, and chronic fatigue2.


  • Average length of opioid treatment was 4.5 years
  • 73% reported side effects
  • The most common side effects were constipation, fatigue, and nausea
  • 69% of patients with Migraine for 3-15 years prior to opioid use responded positively to treatment
  • 61% of patients with Migraine for 16+ years prior to opioid use responded positively to treatment
  • The abuse rate was 26%
  • Patients with comorbid personality disorder and those with a history of abusing short-acting opioids were at increase risk of abuse.

For the purpose of this study, abuse included a wide variety of behaviors, including things like accepting another prescription from a dentist or taking the medicine for pain other than Migraine. Abuse is on a continuum from the occasional use of a family member’s Rx to habitual abusers. Not everyone who abuses opioids is an addict2.

The study recommends that treatment be divided into three phases:

  1. Initiation – risk assessment, patient education, medication agreement
  2. Monitoring – Ongoing assessment of patient’s pain, overall functioning, side effects, and medication compliance
  3. Transition – Switching to non-opioid pain management when abuse occurs or treatment fails to have the desired effect

Robbins states that only 50% of chronic migraineurs do well on long-term preventives. He recommends careful screening of these patients to determine if they are candidates for long-term opioid therapy. A select few will do well.  Ideal candidates are more likely to be young, with no prior opioid abuse, and good coping skills. Patients who smoke cigarettes and many with mental illnesses are not at increased risk for abuse and should not be excluded on those grounds. Those who previously abused opioids, older patients, and those diagnosed with personality disorders were at an increased risk for abuse2.

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. American Headache Society (2007). Opioid therapy for Migraine, Headache, doi: 10.1111/j.1526-4610.2007.00931.x, retrieved 2/15/2015 at
  2. Robbins, Lawrence, MD, (March 2009). Long-Acting Opioids for Refractory Chronic Migraine, Practical Pain Management, Vol. 9, Issue 6, retrieved 2/15/2015 at
  3. Rothrock, John F., MD, (July 2008). Treatment-refractory migraine: the case for opioid therapy, Headache, 48:850-854, retrieved 2/15/2015 at


  • Newdancerco
    3 years ago

    I knew this from my work in forensics and now in a pharmaceutical startup working on ultra long acting opioid and antiopioid treatments (1-3 months per shot) but if I tried to say it to a doc it seemed I was deemed a drug seeker. All I want is for my pain to be treated like chronic back pain so I can work. Please?

    Either that, or someone show me how to apply for disability. Because it is bad enough I will lose another job if it doesn’t improve.

  • Karen
    4 years ago

    Great article! It’s nice to see that other pain meds are being considered for migraine. I hope more studies are done to find even more options!
    I have had migraines for almost 40yrs now with chronic migraine for approximately 8yrs. I was recently told by a pain management doctor that nerve pain is non-receptive to opioids; however my GP thought I should give them a try since Very little helps much. He put me on a regimen of 1 pill every 6 hrs since I also have occipital neuralgia 24/7. I have to say that I tried this for a month and I still had just as many migraines every week and the occipital pain was only marginally reduced. I was however, nauseous constantly. I have since stopped the opioids and I have found that my normal migraine rescue drugs work much better now. I’ve gone back to Imitrex injectable for moderate relief.
    On a side note, I am getting a neural stimulator implanted next month for the occipital pain. I’m hoping it also has a positive effect on the migraines. Wishing you all wellness and pain free days!

  • AnnieInAcworth
    4 years ago

    I took the opioid Nasal Spray Stadol for about 15 years with ZERO ill effects. It had a big-time reputation for abuse. My neurologist (fine man, may he R.I.P.) and I tried everything else and I had no other options. I was given one teeny-tiny bottle I had to make last 6 months, so I reserved those few doses for “no other choice” situations. I NEVER abused it. It was removed from the market because of the potential for abuse. I am allergic to ALL other pain meds, but Stadol. Now I lay on the cold bathroom floor and wretch for the 6-8 hours my migraines last. Suxtobeme…

  • Kate
    4 years ago

    Great article, Tammy! I have NDPH (constant headache for 9 years) and episodic migraine. For the NDPH, I am in the minority and have resorted to daily opioids (Methadone). Although Methadone has some higher risks, anecdotally it seems to be especially helpful for headache patients (including those who didn’t respond to other opioids), and patients seem to build tolerance to it slower.

    After years of failed treatments, as I responded to as needed opioids, I was lucky enough to have a neuro who suggested trying the meds daily and a primary doc who agreed. I now see a pain management specialist, which is definitely the way to go if any patient is beyond infrequent opioid use, as they have the education & experience in prescribing them.

    Its definitely a last resort to take daily pain meds, but it has been life changing for me, and the only thing to help. There are also some challenges & side effects, and with the changing pain management with opioids climate, a risk of getting cut off at any time (I’ve already been required to cut my dose by 2/3).

    Unfortunately most doctors consider opioids to be contra-indicated for treating any headache condition, citing the risk of rebound and hyperalgesia. I’ve had numerous doctors (even those I am not even seeing for pain/headache) say I need to get off of them, but offer no reasonable alternative treatment plan.

    However, I think in certain cases they should be considered. I see no reason to treat headache pain differently than any other pain. As my pain levels are significantly decreased than pre-opioids, I wouldn’t care if I was in rebound (but I don’t think I am). Best wishes.

  • ChristieS
    4 years ago

    I agree. Headaches should not be treated differently. There are days when it is the only thing that will even touch the pain. My internist feels I should not have to suffer. My old neuro wanted me off all pain meds, even tylenol. I switched neuro docs after that. My life is turned inside out enough with the migraines, I don’t need the pain levels to go with it. I take hydrocodone.

  • ChristieS
    4 years ago

    I do take an opioid for my migraine pain. I have suffered from migraines for nearly 50 years. Nothing really helps. Botox decreased the frequency, but drastically increased the intensity and pain levels. My internist feels I should not suffer needlessly. I get a prescription at every visit (every 90 days) for 90. I always use the same pharmacy. The script is written for 1-2 every 8 hours as needed. I always take just 1, and if pain hasn’t significantly decreased after about 3 hours, I will take the second one. Only once have I had to call for a refill. I have no side effects. My neurologist is aware that my internist prescribes them for me, and is okay with it since I obviously have no history of abusing them. I don’t think I could manage some days without it. I chart my headaches with an app on my phone and keep detailed records for my internist and neurologist. The opioid therapy is about the only thing that even comes close to helping.

  • ChristieS
    4 years ago

    I should also add that my opioids are not my first choice. If my pain is below a 4-5 (which on my pain scale is just slightly less than giving birth), I will try a dark room, nap, and some tylenol before hitting the heavy duty meds.

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