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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.

Acute treatment

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

Preventive treatment

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:

  1. Side effects dramatically increase with daily use
  2. GI dysfunction
  3. Respiratory depression
  4. Sudden cardiac death
  5. Sleep disturbance (75% had sleep apnea)
  6. Sexual dysfunction
  7. Mood alterations
  8. Mental fog
  9. Lack of motivation
  10. Deficiencies in memory, attention, psychomotor speed (may be result of pain)
  11. Opioid induced hyperalgesia (increased pain)
    1. May be misdiagnosed as tolerance or worsening disease
    2. Presence of allodynia & increased pain with increased dose
  12. 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:

  1. Over 30 years old
  2. Frequent, disabling pain
  3. History of good compliance
  4. Refractory pain
  5. Other measures contraindicated
  6. Patient well-known to prescriber
  7. No history of addiction, drug-seeking, or serious mental illness
  8. Written contract, drug screening, regular office visits, counseling, etc.

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

  1. Levin, Morris MD (2014). Opioids in Headache, Headache, 54(1): 1221, retrieved 2/15/2014 at http://www.medscape.com/viewarticle/819417_1.

Comments

  • Erin
    4 years ago

    I’ve found these articles interesting. I’ve also had chronic and daily migraines for about 13 or 14 years now. For me the only medications that have proved useful were Lyrica, (no one is certain why it worked),I take Elavil, Inderal, and Riboflavin as preventatives. I also get Botox injections every 3 months. I’ve tried nerve blocks, massages, and several chiropractors. Botox has helped somewhat. The rest other than my preventatives have made things much worse. A few years ago I found a Doctor who was not afraid of opioids. I take oxycodone only twice a week for migraines that won’t break. And if I know that won’t work, I’m allowed two treatments a week for the migraines. If I’ve taken the Oxycodone at home,I don’t get a treatment. My treatments are either a shot of Morphine, Demerol, or an IV of Benadryl, phenergan, Ativan, and Lidocaine. At times all are successful at relieving my pain. But Demerol with Toradol works the best for me. The Demerol makes the pain better and the Toradol keeps the intense pain away for a longer period of time. If I didn’t have my oxycodone and treatments, I would literally not make it through the day. They allow me to get out of bed, and that’ll a really big deal for me. I know everyone is different, but I wouldn’t be here without my opiods. I don’t judge. I wish more doctors believed in not judging just because something they don’t like helps a lot of people. And studies only cover those people. Some of us really do make it through the day because opiods work for us. I also discusse MOH with my doctor and neurologist frequently. I do not suffer from this. I follow their instructions to the letter. I never take more than prescribed. Sorry to kinda rant, but opiods have pretty much saved my life. I feel very strongly about this. No disrespect meant.

  • Tammy Rome author
    4 years ago

    Sounds like you made a responsible and effective choice. One of the important factors in prescribing opioids is that the doctor know his/her patient. When you have a good relationship with your doctor, it can make a lot of difference.

  • Herrenfam
    4 years ago

    I have many family characteristics and personal characteristics for a person who shouldn’t take opioids for my intractable migraines. I have bipolar disorder, my father had it, my father and his brother were both rock-bottom drunks (though my dad had 20 years of sobriety when he died of cancer) my parents and many of my relatives used drugs in the 70’s and 80’s. So i think a lot of those opioid criteria are crap. I responsibly used stadol for 2 years without trouble. Now I’m seeing a neurologist that specializes in migraines and I’m off the stadol and trying more preventatives, getting nerve blocks and trigger point injections. I’ve only been under this new treatment for two months, and I’m only noticing a small difference. When my dr went on vacation (he has an acute care facility inside his office) I got a horrific migraine for six days. It was either a three day hospital stay to get dilaudid every four hours till my migraine went away or use the stadol and stay at home. I chose to stay at home. And I made it through just fine. A little bumpy, but I got to stay home.

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