Migraine-specific opioid treatment
In this third installment of our series on opioid medications we will be exploring some of the discoveries made about the use of opioids to specifically treat migraine. In case you missed the first two, please take a look at A balancing act – opioid use throughout history and Risks of long-term opioid treatment to catch up.
According to a 2014 article published in Headache, Dr. Morris Levin analyzed the advantages and disadvantages of using opioids to treat headache disorders. He addresses both acute and preventive treatment1.
Dr. Levin cited a 2008 study review led by Dr. Freidman that compared the use of Demerol to other migraine treatments. The review determined that Demerol was less effective than both DHE and anti-emetic drugs and was equally as effective as Toradol. When compared to DHE, Demerol increased dizziness and sedation. However, it did have fewer side effects than anti-emetics. Overall, the side effect profile of Demerol was similar to Toradol. Dr. Friedman and colleagues also discovered that recurrence of pain within 24 hours was common with all treatments1.
Unfortunately, given the results of long-term opioids use, most doctors do not recommend using it except in rare cases when all other treatments fail. It becomes clearer why doctors are so reluctant when we understand these risks1.
- When taken frequently, patients are 6 times more likely to be depressed and have 9-fold higher rate of ER visits. They also have significantly higher levels of disability.
- Newer opioids, like Tramadol, do not have the same risk of dependency or side effects. However, tolerance and dependence can occur.
- Studies have confirmed that regular use of opioids does increase the risk of Medication Overuse Headache. It also increases the risk of transformation from episodic to chronic migraine.
- Regular opioid use can also result in patients being less responsive to other acute migraine treatments.
- ER visits are more frequent
Dr. Saper led studies in 2004 and 2008 to examine the use of opioids as preventive therapy for chronic, intractable migraine. In the beginning, results looked promising. As time went on, several problems occurred. One of the most troublesome observations was that despite positive self-reporting, patients’ disability scores didn’t improve. Researchers questioned the validity of patient reports and wondered whether certain properties of the medication were skewing the results. In addition to pain relief, opioids also enhance mood and reduce anxiety. So patients were happier and more relaxed even though they weren’t functioning any better from day to day1.
Still, there is a lot to be said for the benefits of an improved mood. Maybe there are safer treatments that will produce the same effects.
But the problems didn’t stop there. The longer patients continued on opioids therapy, the more side effects they experienced. Some of the potential side effects include1:
- Side effects dramatically increase with daily use
- GI dysfunction
- Respiratory depression
- Sudden cardiac death
- Sleep disturbance (75% had sleep apnea)
- Sexual dysfunction
- Mood alterations
- Mental fog
- Lack of motivation
- Deficiencies in memory, attention, psychomotor speed (may be result of pain)
- Opioid induced hyperalgesia (increased pain)
- May be misdiagnosed as tolerance or worsening disease
- Presence of allodynia & increased pain with increased dose
- Increased risk of Medication Overuse Headache
Despite all the bad news, Dr. Levin still maintained that there are a few select cases for which opioids therapy results in an improved quality of life. Patients whose headaches have not responded to all other treatments and those who cannot tolerate the side effects of other therapies may be candidates for opioids under the following guidelines1:
- Over 30 years old
- Frequent, disabling pain
- History of good compliance
- Refractory pain
- Other measures contraindicated
- Patient well-known to prescriber
- No history of addiction, drug-seeking, or serious mental illness
- Written contract, drug screening, regular office visits, counseling, etc.
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