Opioids and Migraine: A Tough Conversation

At one of the seminars I attended at a recent American Headache Society Symposium, the question was posed, “Is There a Role for Opioids and Bultalbital-Containing Medications in the Treatment of Headache?” As part of the “Controversies in Headache Medicine” series for the symposium, what made it particularly interesting was that it included speakers on both sides of the debate. Far from the one-sided presentation expected, given the prevailing current attitudes towards opioids, what ensued was a fascinating and thought-provoking session that ended up leaving much on the table to be considered.

Speaking for and against opioids

Speaking for the defense of opioid and butalbital-containing medications in certain situations was Dr. Paul B. Rizzoli.¹ In the presentation, his position could be summed up as: Judicious use is preferable to complete avoidance.

Speaking against the use of opioid and butalbital-containing medications was Dr. P. Christopher H. Gottschalk.² In the presentation, his position could be summed up as: Don’t do it.

Efficacy and risk of addiction

The key questions raised were efficacy, risk, and whether opioids should ever be considered for headache disorders.

A quote from The International Association for the Study of Pain notes, “Opioids are indispensable for the treatment of severe short-lived pain during acute painful events... IASP’s 2010 Declaration of Montreal states that access to pain management is a fundamental human right.”³ Concerning the risk of addiction, a quote from the US Pain Foundation states, “Repeated research has shown that the actual risk of addiction in medically managed chronic pain patients is between less than 1% and 8%.”⁴ and, in an American Headache Society article, we read, “Evidence strongly suggests that opioids are not as effective as acute medications like triptans, but for certain patient groups, they offer a necessary alternative option for pain relief.”⁵ Morris Levin, MD. summarizes, “… there are patients for whom opioids on occasion are optimal acute treatments.”⁶

Risk versus benefit

The risks associated with opioids are well known and highly publicized, including addiction, dependence, medication overuse headache (MOH, which is now becoming known as medication adaptation headache), and more.⁷ However, the concept of risk is not one that is unfamiliar to people with migraine. The reality is that ALL medications carry both benefits AND risks. In fact, it is common for someone experiencing a migraine attack to decide to delay treatment due to fear of side effects. The question to be asked should not focus so much on whether opioids carry risks in the general sense, but rather for this specific patient and their individual situation, do the benefits outweigh the risks or vice versa? When the alternative is to leave a patient in devastating pain, is it humane to ignore a class of medication that can help relieve that pain? Pain relief is a basic human right but one that is frequently devalued.

Telling a story or proving a point?

One of the most interesting aspects of statistics is how two people can see the same data and arrive at different conclusions. For example, if a study’s data shows that people with migraine who use opioids are more likely to become chronic than those who do not use opioids, does that data prove opioids cause chronic migraine? OR… does it show that patients who are at risk of becoming chronic are more likely to end up taking opioids? Another example would be data that shows opioid use for migraine in the emergency department is more prevalent than in other areas of disease management. Does this data indicate inappropriate opioid use in emergency departments for migraine, OR that the patients treated there are more likely to have exhausted all other options by the time they reach the emergency department?⁷ Because statistics from clinical studies are often more descriptive than causative, it is highly suspect when one perspective is presented as absolute fact. Again, 'statistical significance' does not necessarily mean causation, and using data in this way can be highly detrimental to patient care.

Where does that leave us?

When looking at the complex and highly emotive topic of opioids, it is crucial to look at the whole picture for each individual with migraine. Medicine is not a one-size-fits-all and never is this more true than with a spectrum disease that is extraordinarily complex and about which much remains unknown. Factors to take into consideration include:

• Using opioids as a shortcut to avoid comprehensive disease management
• Personal or family history of substance abuse
• Contraindications of opioids to other medications being taken
• History of, and potential for, medication adaptation headache
• Inability to take migraine medications such as ergots or triptans
• Lack of efficacy from medications such as ergots, triptans and gepants
• Pregnancy and/or nursing

Comparison versus toolbox option

In summary, the debate at the American Headache Society symposium was encouraging. It has been incredible to see many new migraine treatments approved for use in the US over the past few years. However, while having new and targeted options is a huge step forward, that doesn’t negate the question: What about when these targeted options do not work? I would posit that any headache specialist who has not come across a patient who fits this category is either not seeing many migraine patients or is not listening to those patients and their experience.

Can opiates be counterproductive for some patients? Yes. Are they sometimes prescribed when it is unjustified? Yes. Are they inappropriate for first-line treatment for migraine? Yes. However, we also have to ask: Do they play a key and vital role for a specific population of people with migraine? Yes! Condemning someone to a life of intractable pain simply because the supposed ‘risks’ outweigh the subjective ‘benefit’ for the population, in general, is inhumane. A summarizing statement by the US Pain Foundation states, “Because of the associated risks, opioid medications should not be a front-line therapeutic option. But they do have a role for certain patients, especially those with severe pain, who have tried and failed other treatments. Working closely together, health care providers and their patients must decide whether the benefits of opioids outweigh the risks.”⁸