Why Won’t My Doctor Prescribe Narcotics?
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One of our readers asks, “Why do neurologists not want to prescribe narcotics even if that’s the only thing that stops the pain?”

When used for a limited time, narcotics are very good at controlling pain. Recovering from a serious injury or surgery without them would be quite miserable. The trouble is that these medications don’t have a great track record when used long-term. In fact, more often than not, they make Migraine worse.

Good intentions, bad outcome

There are three reasons that narcotics are not a good treatment strategy for migraine.

#1 – They don’t stop a migraine attack.

While pain is certainly a symptom of Migraine for many people, it is not the only symptom. Opioids are good at one thing – relieving pain. They do absolutely nothing to stop the neurological process in the brain that is setting off vasodilation, inflammation, or the electrochemical disruptions of neurotransmitters. We need treatments that stop that process. Patient advocate, Teri Robert explains it like this:

“…we need to prevent as many Migraines as possible, and when we get one, stop it as quickly as possible…Pain medications such as opioids can’t do that. All they can do is mask the pain for a few hours, leaving us to hope that the Migraine [attack] runs its course and is over before the medication wears off. Pain medications can address only one of the symptoms of a Migraine, the pain. They can’t address nausea, vomiting, photophobia, phonophobia, osmophobia, allodynia, or any of the other symptoms.”

#2 – They cause opioid-induced hyperalgesia

Over time and with repeated use, the body becomes accustomed to narcotic pain killers. This isn’t necessarily addiction, but it is a problem. When this occurs, the body becomes more sensitive to pain. Gradually, the pain gets worse and worse. Plus, this hypersensitivity to pain can spread across the body, encompassing much more than just the headache pain of Migraine. This hyperalgesia is distinctly different from the allodynia present during a Migraine attack because it is directly dependent upon the use of narcotic pain medicine.

#3 – They put you at risk for Medication Overuse Headache

In patients already susceptible to headache disorders, using any type of pain medicine more frequently than twice a week can contribute to the development of Medication Overuse Headache. The problem also develops slowly and may not be noticed until it’s too late. The regular use of pain medicines (narcotics included) more often than twice a week for more than 3 months puts you at high risk for this problem.

But, Preventives don’t work!

It is true that some patients do not respond well to standard preventive treatment. But let’s be honest. Few of us actually see a headache specialist who is willing to keep trying new strategies until something finally works. Instead, we see primary care doctors or general neurologist with limited training in the treatment of migraine. When the typical preventives fail, they run out of options, shrug their shoulders, tell us we have to “learn to live with it,” or refer us to mental health services.

Unfortunately, many patients are left to struggle on their own with minimal relief for far too many years before seeing a true headache specialist. By the time they reach the type of doctor who could have helped prevent such poor outcomes, the damage has already been done. This makes the job of finding a good preventive strategy much more difficult.

The best way to do that is to work with a headache specialist who will collaborate with you to develop a treatment plan that is both effective and safe. Results like that can take some time.  It took me several years to finally find a good solution. Even now, my specialists and I are frequently adjusting my treatment plan for optimal results.

First, do no harm

When a patient asks for narcotic pain killers, it is most often after traditional acute medicines have failed and/or one or more preventives have failed. An ethical physician would not risk making a difficult situation worse by introducing a treatment that is proven to increase both the frequency and severity of symptoms. In short, narcotics make headache pain worse over the long haul.

Treating the pain with narcotics may seem compassionate on the surface. However, to do so long-term is short-sighted. In the long run, narcotics will only make migraine more frequent, more severe, and more difficult to treat. A doctor who refuses to prescribe narcotics is actually doing you a favor.

view references
  1. Cowan, R. M., MD. (n.d.). Opioid Narcotics and Headache - American Migraine Foundation. Retrieved November 28, 2016, from https://americanmigrainefoundation.org/opioid-narcotics-and-headache/
  2. Robert, T. (2010, February 10). Opioids for Migraines - Why Not? Retrieved November 28, 2016, from http://www.healthcentral.com/migraine/medications-462715-5.html
  3. Treating Migraine Headaches. (2013, February). Retrieved November 28, 2016, from http://www.choosingwisely.org/patient-resources/treating-migraine-headaches
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