Migraine & Opioids: An Evolving Consensus?

October 26, 2016

shutterstock_159128441Popping up in the Headlines
If you’ve been paying attention, you’ve noticed that the abuse of opioids has been garnering increased media attention. It seems rarely a day goes by without some mention of the issue and the problems it has caused. The use of this class of these drugs such as prescribed narcotic painkillers like Vicodin and Percocet  – often combined with over the counter (OTC) pain relievers such as acetaminophen – to illicit “street drugs” like heroin, has been increasing steadily. Often talked about as an “epidemic,” and causing alarm from communities, law enforcement, and medical officials across the country has certainly not been ignored by the media.

This is for good reason: While opioids are effective when prescribed and used properly for certain acute pain, they carry a high abuse potential and, thus, many become addicted to them. According to the American Society of Addiction Medicine, drug overdose is the single largest cause of accidental death in the US, and the improper use of opioids is driving this epidemic [see Reference  #1].

Mitigating Migraine Pain
Still, prescription of these drugs is often recommended for migraine pain. The efficacy of this class of drugs temporarily relieving pain cannot be denied; however, concerns about how well they work for recurring conditions like migraine are being raised. Since this is a chronic condition—one that is chronic with no determined end—as opposed to something that will eventually heal eventually, like a broken arm, the use of such drugs are becoming more regularly prescribed for chronic pain, as opposed to acute pain that will go away. They’re often prescribed to be taken “as needed.” However, issues arise when patients use them with a very loose definition of that term, especially when increased dependence and tolerance makes “as needed” a term that can be further misunderstood by patients. Beyond risks of overdose, there are a number of other side-effects, including a worsening of pain symptoms, sedation, intoxication and drowsiness, and others.

It’s for these reasons pain management specialists are starting to look at the issue of opioid use for migraine more closely.

What Are Opioids and How Do They Work?
Opioids and its derivatives is a centuries’ old drug used for pain. Today, we know them most often in pill form. Some commonly prescribed opioids include:

  • Meperdine (Demerol)
  • Codeine (Tylenol)
  • Oxycodone (Percocet)
  • Hydrocodone (Vicodin)
  • Hydromophone (Dilaudid)
  • Morphine

Opioids attach to the receptors in the brain, spinal cord and gastrointestinal tract that send pain signals through the body. Through attaching themselves, they deaden the pain and numbing the effects of pain. In terms of migraine, they treat the symptom—pain—and not the cause, and therefore does not directly treat or cure migraine.

For certain acute pain, the relief provided by opioids can be instrumental; there’s a reason they’re so often indicated. The big question, however, is how well they work for chronic migraine and whether the risks outweigh the benefits.

A Good Treatment Plan?
Recent studies strongly suggest there’s a growing shift in medical fields that opioids, in most instances, are not the best way to go for pain relief. In an article published in Headache, Dr. John F. Rothrock, MD states there’s evidence that, with prolonged use, the body becomes more tolerant of the drugs, requiring higher doses to achieve the same effect. Furthermore, he urges, “Do not be fooled! No one is immune to the addictive potential” of this class of drugs. For some, especially those prone to addiction, administration of opioids can be a recipe for disaster; their efficacy wears off, higher and higher dosages are needed, and thus become highly habit-forming.

Taking a longer-term view, it’s clear that the perfect solution is most likely in a pill bottle. In an extensive review of the available evidence aptly titled “Opioids Should Not Be Used in Migraine,” Dr. Stewart J. Tepper puts it cleverly, writing “[u]se of opioids in migraine is pennywise and pound foolish.” He reports long-term opioid use has “minimal effectiveness;” and may very well negate the positive effects.

Proper Use
Still, migraine pain is incredibly disruptive and opioids are often prescribed to mitigate them. Many pain management practitioners, then, want to not completely rid their use, but wish to educate the medical community and patients how they can be properly used. Dr. Rothrock provides these tips (see Reference #3), though of course, your own physician should be the first person to go to for a safe and effective medication plan:

  • Timing of Administration: Make sure to wait until migraine pain is moderate to severe; this will ensure the drug takes effect when the pain is at its worst. Taking it too early may lead to overuse once the initial effect wears off.
  • No Mixing: When opioids interact with other drugs, such as alcohol, the risk of dangerous side-effects increase. Drowsiness, intoxication, and nausea may occur. And since both are processed through your liver, this vital organ may become overly taxed and prone to lasting damage over time.
  • Limit Use Over Time: According to Dr. Rothrock, opioids should not be taken more than 10 days a month. More frequent use increases the risk of higher tolerance and addiction.
  • Listen to Your Body: Be mindful of allergic reactions to opioids. Itching, for example, is an expected side-effect.  If this is accompanied by a swelling or redness in the throat, lips or mouth, there may be an allergic reaction and you should your doctor immediately.

Options & Choices
As difficult as migraine may be to manage, with debilitating and unpredictable periods of pain, there’s no reason to believe pain relief is no longer possible. Beyond opioid prescription, a wide range of treatment options are available, many of which treat core of the condition itself. This is even the case for the most painful migraine cases.

Though the medical community is becoming more aware and, thus, stricter, with an opioid prescription, it’s important to know that medical professionals do not want to see patients in pain. Nor do they wish to see patients continue in pain while becoming addicted to a substance. If you have a doctor you trust, you can rest assured they are looking out for both your pain and your overall health.     

If you’re suffering from chronic migraine, talk to a patient care coordinator at Migraine Treatment Centers of America. These professionals strive to help people find lasting and effective relief using cutting edge technologies and create lasting patient provider partnerships. Learn more by calling (855) 300-6822. 


  1. Jones, Christopher M. ‘Heroin Use and Heroin Use Risk Behaviors among Nonmedical Users of Prescription Opioid Pain Relievers – United States, 2002–2004 and 2008–2010’. Drug and Alcohol Dependence 132, no. 1-2 (2013): 95–100. Accessed November 22, 2016. doi:10.1016/j.drugalcdep.2013.01.007. http://www.asam.org/docs/default-source/advocacy/opioid-addiction-disease-facts-figures.pdf.
  2. Tepper, SJ. ‘Opioids Should Not Be Used in Migraine’. Headache. 52 (May 11, 2012): 30–34. Accessed November 22, 2016. https://www.ncbi.nlm.nih.gov/pubmed/22540203.
  3. Rothrock, John F. ‘Opiate and Opioid (“Narcotic”) Therapy for Acute Migraine Headache’. 2010. Accessed November 22, 2016. http://www.medscape.com/viewarticle/725867.

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