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Why Won’t My Doctor Prescribe Narcotics?

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.

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

  1. Cowan, R. M., MD. (n.d.). Opioid Narcotics and Headache - American Migraine Foundation. Retrieved November 28, 2016, from
  2. Robert, T. (2010, February 10). Opioids for Migraines - Why Not? Retrieved November 28, 2016, from
  3. Treating Migraine Headaches. (2013, February). Retrieved November 28, 2016, from


  • Dr. Alex Mauskop
    3 years ago

    Thank you Tammy – you give a very good summary of our attitude toward narcotics. But ccf23 and Rosie have a point. Fortunately, it is a rare patient who responds to an opioid (narcotic) and nothing else. But for those rare patients it can be a life saver. Over the years I’ve had some women with menstrual migraines that landed them in an ER every month and the only treatment that worked was a shot of Demerol (meperidine) or morphine. The prohibition of narcotics should not be absolute and there is nothing wrong with the doctor prescribing even an injectable opioid drug if it is used on one or two days a month. I also have a handful of patients who are maintained on a daily narcotic. Such patients must not have worsening of their migraines from the medication, must not experience side effects or need to escalate the dose, must return for regular visits, must remain functional, and must not exhibit aberrant behaviors (losing their meds, getting meds from more than one doctor, calling for refills before they are due, missing appointments, etc.). In addition to these requirements, we look for factors that increase the risks, which include personal or family history of any addiction, including alcoholism, living with an addict or someone with a criminal history, history of a serious psychiatric illness, and other.

    I want to stress that this is an exception that applies to fewer than one in a thousand of chronic migraine patients. I rarely prescribe an opioid to someone who has never tried it. Usually, the patient had been given a narcotic in an ER or had some left over from surgery and found it to be effective.

    Despite all the risks and trepidations, this last resort option can still be a safe and effective option for a very small number of patients.

  • rosie.smiles
    3 years ago

    Dr. Mauskop,

    Thank you!!! I appreciate your view on this. I think you have a very balanced opinion of narcotics for migraine. I live in Maine, so I am very thankful that I no longer need hydrocodone for migraine, as a law just went into effect which prohibits narcotics for chronic pain. I was one of those rare patients that didn’t respond to anything but narcotics, and I was extremely grateful for them.

    It aggravates me to no end how people with migraines or other chronic pain are treated like drug seekers or criminals for wanting relief, and are being ‘punished’ because there are those that abuse drugs. I absolutely don’t think that narcotics should be carelessly prescribed; but sometimes giving someone a break from severe pain when all else fails and one is in too much pain to even sleep is just the only merciful thing to do.


  • rosie.smiles
    3 years ago

    I totally agree, ccf23. My thoughts exactly. I used to have chronic intractable migraine (I had migraine surgery last year and that totally stopped my migraines!!!), and hydrocodone was the only thing that helped. No, it did not “abort” a migraine, but it kept me from going to the ER. It dulled my pain enough that I could relax and try to let the migraine pass. When I was more relaxed and groggy from the pain med, I felt the migraine passed sooner than if I was wide awake, tense, and maybe crying from the unrelenting head pain. I tried Botox, nerve blocks, preventative meds, all 7 of the triptans, just about everything OTC, etc. My neurologist mercifully prescribe hydrocodone. I was so sick and miserable, and that helped me make it through. I didn’t take it a lot either…I just reserved it for the most severe attacks when I could hardly stand it but didn’t want to be taken to the ER. I didn’t take it enough to be at risk for rebound headaches. I think it kept me from being worse off emotionally. At least something dulled the pain. That neurologist was caring and compassionate and did his best to help me. Although he wasn’t familiar with migraine surgery, he looked it up when I asked him about it and he referred me upon my request to the surgeon who eventually operated on me. I have utmost respect for that neurologist and I believe he did the right thing by giving me a RX for hydrocodone (Vicodin).

  • ccf23
    3 years ago

    I believe that narcotics can be appropriate in some cases. I agree that seeing a headache specialist and multiple good trials of preventatives is mandatory, but if you are five years in and find no relief from anything including nerve blocks, botox, etc., an occasional narcotic can be the compassionate thing to do for someone living in fear and pain.

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