Opioids for Migraines - Why Not?

Patient Expert

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There are many good questions about Migraine treatments. One that comes up with some regularity is, "Why won't my doctor prescribe narcotics / opioids for my Migraines?"

Although I wouldn't presume to speak for any doctor, let alone all doctors, I can offer you some information that helps explain this issue as well as some words of wisdom from some Migraine experts.

A question we have to ask ourselves is, "What's the goal of the medications we take when we have a Migraine attack?"

There are several ways to answer this question. My goal for my medications is, to put it in one word, "relief." But what does that mean? I want two kinds of relief:

  • Lasting relief from the headache, when there is one, and all the other symptoms the Migraine attack is causing.
  • Lasting relief from what the Migrainous process is doing in my brain. I want to know that any dilation of the blood vessels, the inflammation of the surrounding nerves and tissues, the fluctuation of levels of neurotransmitters such as serotonin, all of it, are stopped.

Those are my goals for medications at that point because there's growing evidence that Migraine is a progressive brain disease. Growing evidence that we need to prevent as many Migraines as possible, and when we get one, stop it as quickly as possible. For more information on this issue, take a look at our article Is Migraine a Progressive Brain Disease?

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 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.

Another problem with opioids (Demerol, codeine, hydrocodone, etc.) and barbiturates such as the butalbital in Fiorinal and Fioricet can cause other problems as well. Research is showing that ANY use of these medications is associated with increased risk of transformed Migraine. You can read more about this issue in Transformed Migraine - Risk Increased by Some Medications.

An issue with any medication we take when we get a Migraine attack is the possibility of medication overuse headache (MOH), aka rebound. Essentially, MOH occurs when we take these medications too frequently and they actually complicate the situation by creating medication overuse headache.

One of the biggest frustrations to those of us with frequent Migraines or headaches is that pretty much anything we take when we get a headache or Migraine can cause MOH...

  • ergotamine medications such as DHE-45 and Migranal Nasal Spray.
  • triptans - Imitrex, Maxalt, Zomig, Amerge, Relpax, Axert, and Frova -- as well as Treximet, which is a combination of Imitrex and Naproxen Sodium.
  • simple analgesics such as acetaminophen
  • opioids such as codeine, morphine, Demerol, Dilaudid, etc.
  • barbiturates such as the butalbital in Fiorinal and Fioricet
  • a combination of any of the above.

Some sources say the usage of some of these medications must be limited to 15 days a month; the use of some must be limited to 10 days a month. The rule of thumb still followed by many is to not take these medications more than two or three days a week. You can read more in Medication Overuse Headache: When the Remedy Backfires.

Probably the biggest frustration is for those who have Migraines or headaches more than those two or three days a week. We still need to function, even if we've already used those medications as many times as we're supposed to in any given week. We have lives, jobs, families who need our attention. We're trying to maintain a decent quality of life, but how are we supposed to do that if we're in pain.

The answer to this dilemma isn't simple or easy. It lies in Migraine and headache management:

  • Identifying our triggers so we can avoid them if at all possible, thus reducing how many Migraines we have.
  • Working with our doctors to find effective preventive regimens that reduce not only the frequency of our Migraines or headaches, but the severity as well.

That answer can be a very bitter pill to swallow (pun fully intended). The bottom line, however, is that this is what's best for our health. In the short-term, it seems almost punishing. In the long-term, however, when we can push ourselves to look at it objectively, it makes sense. If, while we're trying to find that seemingly elusive preventive regimen that works for us, we overuse medications, use opioids that can increase our risk of transformed Migraine, and get our bodies messed up from those medications we take for Migraine attacks, it will take far longer to find an effective preventive regimen, AND we can do some damage to our brains and other organs in the process. Let's remember that when we're looking at the medications we take when we get a Migraine (prescription or over-the-counter), we're looking at some medications that can cause liver or kidney damage too.

None of this is to say that there is no place for pain medications such as the opioids in treating Migraines and headaches. Occasional use of these medications as rescue medications to be taken when abortive medications have failed or can't be used is a practice with which some doctors are comfortable. You can read more about this in Preventive, Abortive, and Rescue Medications - What's the Difference?

What do the doctors say?

It's one thing to hear all of this from me, but it's another to hear it from the doctors who actually treat Migraine and headache and are the ones who write the prescriptions. I sent this article to several doctors. Here are their comments:

from Dr. Traci Purath; Migraine and headache specialist; Franklin, Wisconsin:

"I think that this is such an important question that you pose. Many of my patients ask this (some are very angry with me that I do no use opioids or barbiturate in the treatment of headache). The reason is the pathophysiology of the disease itself. I feel that using opioids and barbiturates only tell the brain "yea" I have a headache but I don't care". They do NOT resolve the issue- in fact I feel that they cause more problems. I believe that opioids cause increased headaches with increased use as we refer to as "opioid enhanced hyperalgesia (increased sensitivity to pain or enhanced intensity of pain)" - which of course the only treatment for is opioid detoxification. We know that opioids cause habituation and therefore I feel that they do not have a place in the treatment of headaches.

Fioricet is banned in Europe for a reason. It is terribly addictive. Now. Are there times when I have used opioids? Yes- I have used Tylenol #3 in pregnancy or for my patients whom triptans are contraindicated. But I monitor closely and when I feel that there is becoming habituation then I re-look at my preventative.

Teri- those of us who treat headache sufferers care deeply about our patients. We certainly do not want to cause them more problems. I spend half of my "headache life" getting people off these offending agents!"

from Dr. K. Ravishankar; Migraine and Headache Specialist; Mumbai, India:

"Your doctor is actually doing 'good' for you in the long term if he does not prescribe narcotics / opioids for your regular migraine attacks. Because of what I call the 'honeymoon phase' of initial relief, many patients tend to self-medicate themselves with opioids, often go overboard and end up with MOH.

The main dilemma for us doctors is to try and find the right fit and most effective 'combo' of preventives and abortives for every patient. And at the same time we need to be cautious about not having side-effects. It is safe therefore to use opioids only as 'rescue' medicines.

Your doctor knows best what is right for you. Trust him and follow his advice. If you stay away from opioids today, you can live with the hope of a better tomorrow!"

from Dr. Alan Rapoport; Migraine and headache specialist; Los Angeles, California:

"It is only natural for patients with migraine, who are in a lot of pain, to reach for and ask for pain medications. The strongest type of pain relievers are opiates. Butalbital containing medicines like Fiorinal and Fioricet are also strong and they sometimes contain opiates in addition.

As Teri says, these medicines, even though they might relieve some pain or nausea and make you calmer and help you to sleep, rarely if ever work on the underlying migraine process. So you feel a bit better for a short time and usually find that when the medication wears off, the migraine process is still in full swing.

The types of medicines that work the best are nonsteroidal anti-inflammatory medicines like Motrin and Aleve and stronger prescription forms, and the triptans and DHE. Too much of the opiates and even of the best medicines may lead to medication overuse headache and a worsening of your condition.

If your headaches are too frequent, you need less pain medication, good daily preventive medication, effective vitamins, minerals and herbs, behavioral medicine techniques like biofeedback, exercise, etc.

If your headaches are not under good control, rather than pain killers, who need a good neurologist or headache expert."

from Dr. Larry Robbins; Migraine and headache specialist; Northbrook, Illinois:

"In general, MEDICALLY, the reasons not to use opioids in younger people revolve around opioid-induced hyperalgesia (increased sensitivity to pain or enhanced intensity of pain), setting the brain up to need opioids forever. And MOH. In middle age or older, sometimes it is all that we have to offer to help.

BUT, FROM THE DOC'S STANDPOINT, there are other reasons not to prescribe opioids: In a nutshell, some are: Not prescribing them eliminates many (most) difficult phone calls, late nite calls (95% of which are phony...just look at the chat boards, where the migraine person says she called the doc at 11pm, he would not give Fiorinal with codeine late at nite, and a bunch of people commiserate with her, say "bad doc, he is awful". That is ridiculous, just because someone sees a physician, does not mean 24 hour access for addicting meds at his beck and call...in fact, docs who call those in at nite often get sued or complaints to the Dept. of Regulation... anger, tough conversations with patients (as when you have to take them off, etc.)...and eliminated Dept. of Regulation complaints (spouse says: That bad doc got my hubby addicted)....and legal concerns (if a pt. dies, which happens thru accidents or suicide etc, often there is a lawsuit involving the meds....and addiction "I am suing you, you got me addicted, now I am in jail etc. This happens all the time)... Not using opioids eliminates the borderline (and other) personality disorders who hock the doc for these addicting drugs, giving the office a lot of anger and sense of entitlement

SO, by NOT prescribing opioids, for the doc,:1.it is much safer for him in many ways,2. eliminates hassles, tough phone calls (I could go over those tough phone calls with you, but trust me many docs, after a couple of borderlines angrily sit in his office and exclaim, "Ok, I know I was supposed to use only 2 a day, and I used 14, so what AM I SUPPOSED TO DO NOW, HUH??...and will not leave, throws a scene and 3. all the legit medical reasons.

Having said that, I do prescribe them cause we are very good at handling these tough patients, limiting drugs, screening pts, etc...and I do not want to punish the 90% of folks who use these appropriately, instead of the other 10%."

Summary and comments:

The answers to questions about why doctors don't like to or won't prescribe opioids aren't easy, and they're answers some patients won't like. Hopefully, having doctors answer this question directly will be helpful Still, doctors can't change the pathophysiology of Migraine or the impact of opioids on that pathophysiology to fuel answers that will make everyone happy.

Nobody questions the need for relief or the "right" to good treatment. Doctors who refuse to prescribe opioids or prescribe them in limited quantities aren't insensitive to our misery. They're looking ahead and not prescribing medications that could make our situations worse in the long run.


Resources:

Interview. Dr. Traci Purath. February 8, 2010.

Interview. Dr. Alan Rapoport. February 8, 2010.

Interview. Dr. K. Ravishankar. February 8, 2010.

Interview. Dr. Larry Robbins. February 7, 2010.

Medical review by John Claude Krusz, PhD, MD

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