The Confusion About Codeine/Opioids and Migraine
All medicines have dangers attached to them, and opioid pain relief for Migraine is a type of treatment that has additional considerations which should be thoroughly discussed between Migraine patients and their doctors. Some of the reasons may surprise you.
Examples of opioid medicines include:
Because opioids only cover up the symptom of Migraine pain and don’t abort the attack, they’re often discouraged or completely eliminated from a patient’s therapeutic treatment options. Frankly put, if the attack is aborted, the pain and other Migraine related symptoms go away, and that should be every doctor and patient’s goal.
Poor physician care aside, doctors’ reluctance to prescribe opioids can be very confusing for patients. This often leads to feelings of deep depression, abandonment and assumptions that their pain isn’t believed. This is very unfortunate, as both education and good communication between doctors and their patients are usually sufficient to protect them from those unnecessary feelings and the stress and trauma they can induce.
Most patients understand that there are side effects and contraindications for all medicines, including natural remedies. Our pharmacists give us information about these each time we get a new prescription. Opioids are a class of drugs due additional consideration though. Some of these unique considerations are surprising and misunderstood, and terms are unfortunately often used interchangeably by mistake. They consist of four essential categories:
- Tolerance - This occurs when the body gets used to the medicine and eventually requires higher doses to achieve the same level of pain relief. This is a natural consequence of long term opioid treatment for chronic pain. It is normal and expected.
- Dependence - This occurs over time when the body's homeostasis begins to depend upon the medicine's residence in their systems, and removing it can cause serious withdrawal symptoms. This is a physical dependence that occurs normally to all patients on long-term therapy. It is NOT addiction. Patients who are dependent upon their pain medicines to function daily may be unfairly scrutinized for their use of these treatments. This often makes getting appropriate treatment difficult, with each trip to the doctor or pharmacy a stigmatizing or traumatic event. Yet stopping treatment because of lost access to medicines can be dangerous. This perceived threat may make some patients afraid, resulting in anxiety and behavior that may be misinterpreted as evidence of addiction.
- Addiction - This is a behavioral issue when patients acquire the psychological *need* for the medicine that is not necessarily helping them physically. Simply put, addicts take opioids for a high. Patients take them to treat their pain condition. Addiction happens in a very tiny number (3-5%) of patients on opioid pain treatment, however it is one of the greatest fears of patients when they begin long-term therapy. Addiction can occur in tandem with physical dependence and drug tolerance if the use of the medicine has gone on long-term.
- Change in pain pathways - This can result in Medication overuse headache (MOH). MOH can occur in the presence or absence of any of the other three categories. Migraineurs are especially susceptible to this for reasons we don't yet understand. In MOH, opioid therapy physically changes the brain's pain pathways, and this results in a painful condition (a secondary headache type recognized by the International Headache Society's ICHD-II) caused by the medicine that’s being taken to stop pain. This does NOT mean that the patient doesn’t have pain, or that they are over-treating their pain. The patient treats their pain when the pain occurs, without taking too much medicine, but when treated frequently enough, pain pathways in the brain are changed. Because MOH can complicate their Migraines and potentially lead to the chronification of their disease, opioids are strongly discouraged as treatments except in rare circumstances. This isn’t because doctors don't believe patients are in pain, but quite the opposite. It’s because they’re trying to protect them from an even worse situation that can put the patient in a serious spot where they must be left untreated for weeks or months in effort to revert these damaging effects to the brain's altered pain pathways. MOH won’t occur in all Migraine patients, but the majority of Migraineurs who have progressed into a chronic state have a history of opioid treatment of either their Migraines or comorbid pain conditions.
Misuse of these terms creates additional stigma Migraineurs do not need. It can lead to stereotyping patients, unnecessary admittance into a drug rehab program, and mistrust by family and friends, physicians and their patients. Any and all of these can be damaging to a patient already struggling with a chronic pain condition, loss of their ability to live their life fully, rising guilt and plummeting self-esteem.
While some physicians believe that all opioids are bad for Migraine, most doctors and advocates believe that they’re sometimes necessary, though they’re used sparingly. For those doctors who do utilize opiate pain control, pain contracts are often implemented.
Most advocates encourage patients to talk to their doctors about rescue medications and their feelings about the use of opiates. If you and your doctor disagree on their implementation in your own personal circumstances, it may be time to consider finding another doctor with whom you can come to a mutually satisfying agreement. I encourage patients to get these agreements/plans in writing, so when the need for treatment arises, both patient and doctor can be reminded of the particulars, and misunderstandings can be avoided. Written plans can also be helpful for emergency department personnel if necessary.
How much has your migraine disease changed or evolved over time?