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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:

  • Codeine
  • Hydromorphone
  • Meperidine
  • Morphine
  • Oxycodone
  • Tramadol

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.

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.

Comments

  • MaggieMae
    7 years ago

    Thank you so much for this article! You have explained the topic in enough detail, but without my dropping off in confusion. This will be helpful to share with migraine sufferers I met who are so confused & with family & friends. Great job!

  • Ellen Schnakenberg author
    6 years ago

    (( MaggieMae)) – Thank you so much for your encouraging comment!

  • 100dollarheadache
    7 years ago

    along with chronic migraine i have chronic pain issues due to a work related motor vehicle accident back in 2003. i have had 6 surgeries to date. i also suffered a concussion related to that accident. i have had a history of head injuries from child hood. i have had several concussions. i also had stitches or staples in my head many times. football also caused concussion and head trauma. i woke up the next day following my 2003 accident with my first significant migraine, it caused me to vomit, be dehydrated and so sik, i could not function. this led me to call my orthopedic surgeon whom refeered me to my present day neurologist. prior to 2003 i had headache and pain issues from my line of work. after the accident my migraines were diagnosed as chronic migraine , post concussive. i was getting 10 to 12 migraines a month. i was also taking opiates relating to my injuries related to the accident. my doctor also prescribed triptans to help with migraine. some at first did not work. imitrex seemed to work best, the nasal spray. sumerval, in needle form also. timing is everything with migraine. if i get my meds immediately after a symptom occurs, the likely hood is much higher i may recover. seconds can make the differance of being sick for 2 hours or 2 days. along with the triptans my opiate use expanded, i needed more to feel less pain. for 2 years i was in this cycle of taking opiods to manage my pain. it elevated and increased. i was addicted and i began to feel sick from the opiods, i was taking too much opiates and too much tylenol that comes along with it. i went form oxycontin, to percocet, to es vicodin. as the drug went down in strenghth, my quanity of the daily vicodin went up. i eventually got refeered to a pain/addiction specialist. who wanted to treat my pain without feeding my addiction and need for conventional opiates. my pain issues are still significant, but iam still a member of their pain group. i also went to my first appointment there in opiate withdrawal. thats when i began taking buprenorphine/ suboxone- subutex. this is when my life and i finally began to manage my pain with out feeling withdrawal or the need for abusing opiates. buorenorphine along with my migraine meds. have helped me in my battle of fighting chronic pain and migraine. along with gaining knowledge, such as keeping a journal, information on migraine.com, as well as my doctors. i am in the battle. i have cut migraine in half on a monthly basis, going from 10 to 12 to 5 or 6. even with 6 a month i suffer terrible. i lose 1/2 the month to migraine. the whole month i battle pain issues. after 25 year of working at my job, they would not accept me back to work in any capacity. i have had 6 surgeries , my last was 2009.when you have chronic pain issues getting opiates is not a problem with most doctors. when you have permanent injuries and multiple surgeries. they just refill your meds. from my experiance, this is a bad road to go down. that is why i seeked out other alternitives. i could not keep consuming large doses of opiates to fight pain. eventually your pain needs more and more to fight the symptoms, leading to higher tolerance and addiction. menttally and internally i began to feel real bad. buprenorphine has brought peace and stability to my on going fight with pain and migraine. recognizing triggers and avoiding them also help. i still suffer and get real sick at times but i am doing it without all the bagage that comes along with long term opiate use. this battle is hard enough to fight. addiction and abuse only adds to the problem.

  • Ellen Schnakenberg author
    6 years ago

    100dollarheadache – Your last sentence said so much to complement what I was trying to describe. Thank you so much for your thoughtful comment.

  • caradrouin
    7 years ago

    In addition to migraines, I have had ankle reconstruction surgery and two surgeries to fuse three lumbar discs. Almost all opioids as well as Toredol will give me migraines.

    Due to physicians tendencies to view me as hypochondriac because of migraines, the painful conditions leading to the surgeries was not treated for a long time, so I took Advil and Aleve for long periods. Now I cannot take these meds without getting a migraine. Every time I go t a new Dr or have to fill out the whole form because “We are updating our records” all the meds I cannot take will not fit on the form. I carry the list with me in my wallet so I can just refer to it without having to think and remember.

  • Ellen Schnakenberg author
    6 years ago

    caradrouin – You’re a smart cookie! While some doctors will look at that list and consider you further as a hypochondriac, others will practically hug you in relief that you are so organized and proactive! Good job!!!

  • lln001
    7 years ago

    I have had chronic migraines for 20+ yrs and over time I have found what works the best for me is a combination of medicines including some opioid medicines. This is especially true when I have a really bad one that last 4-5 days. Often the morphine or staydohl help break the cycle along with an abortive.
    The ER is a last resort for me. I have boxtox and a stimulator and the combination of the two are working well. Am I cured, no I still have migraines and always will but having the right tools in the box make life liveable again. Don’t give up until you find the right doc to help you. That makes all the difference in the world. Also know you are never alone, even when you feel like it. There are many of us out there!

  • Ellen Schnakenberg author
    6 years ago

    lln001 – Thank you so much for your story. You exactly illustrated the best way to think where Migraine treatments are concerned.

  • DebbyJ56
    7 years ago

    When and where did you get your stimulator????

  • casrak
    7 years ago

    Thank you for your words of encouragement. I am still trying to find the right person to help me.

  • casrak
    7 years ago

    I enjoyed this article very much. As I have been sufferring from migraines for many years now and the worst episodes have been in the last couple of years. I have been on numerous Preventatives and abortives. Yet I am still sufferring, with no immediate relief in site. I also suffer from chronic pain in my leg that I was taking Percocet for for many years. Never over used, just when the pain was so severe that it would bring to tears. The doctors that I was seeing have completely stopped prescribing any type of pain meds and even stopped giving me pain shots when my Migraines were so severe. I am currently seeing a nuerologist through the VA and they have prescribed Gabapentin for pain, but really nothing else. My main concern for taking this medication is that I am a VET and suffer from moderate to severe PTSD/depression and take make meds for that. At this point I am ready to through in the towel and give up because I am in so much pain. When I was able to get pain meds, I would see some relief.

  • Ellen Schnakenberg author
    6 years ago

    casrak – Giving up and throwing in the towel is simply not an option. PTSD certainly is a comorbid condition with Migraine, and I am afraid that perhaps you need to see another doctor – a specialist who deals in nothing but Migraine and headache. https://migraine.com/blog/looking-for-a-migraine-specialist/

    From my personal perspective, it is the Migraine pain that causes me the most issues. Don’t get me wrong, I have even undergone multiple surgeries without benefit of pain relief. I do know pain. That said, when we can get the Migraines under control, often the rest of the pain benefits from those treatments as well.

    It’s very possible that your doctors are having a tough time with the very principles I’ve tried to illustrate here. Again, another reason to see someone who specializes in these disorders. Do you think you can get to see one?

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