Dr Richard LiptonRichard B. Lipton, MD
Although there are existing recommendations against the use of opioids in patients with migraine, opioid use is common among those using prescription medications. Additionally, it is associated with markers of worsened health such as elevated body mass index (BMI), total pain index (TPI) scores, cardiovascular and psychiatric comorbidities, and frequency of emergency facility use for headache.1

The investigators, including Richard B. Lipton, MD, Department of Neurology, Albert Einstein College of Medicine, noted that the modifiable variables which were associated with opioid use included the presence or absence of physician diagnosis of migraine as well as greater monthly headache days. The analysis focused on respondents who reported currently using or having on hand acute prescription pain medication to treat headaches.

The data, which utilized collected information from the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study survey, were presented at the 2019 American Headache Society (AHS) Annual Meeting, July 11-14, 2019, in Philadelphia, Pennsylvania.2

“Opioids are generally not recommended for the treatment of migraine due to limited evidence for efficacy, the risk of dependence and the evidence that opioid treatment is a risk factor for headache exacerbation. The very medication that relieves pain short term may lead to the onset of chronic migraine,” said Lipton in a statement. “Given the chronic nature of migraine, it is critical to find solutions that go beyond acute management, yet we also must be compassionate when patients are experiencing the pain of a migraine attack.”

Previous survey data has reported that roughly 30% of people in a US-based population reported the use of opioids in the treatment of migraine. Of the 2388 respondents with migraine who were currently using prescription medications for headache analyzed by Lipton et al., 36.3% (n = 867).

In addition to the aforementioned markers, those who reported opioid use also reported higher monthly headache days (10-14 days: odds ratio [OR], 1.37 [95% CI, 1.02-1.82]; ≥15 days: OR, 1.62 [95% CI, 1.24-2.13]); medication overuse frequency (OR, 1.73 [95% CI, 1.30-2.31]); presence of allodynia (OR, 1.39 [95% CI, 1.14-1.70]), depression (OR, 1.50 [95% CI, 1.18-1.89]), and anxiety (OR, 1.37 [95% CI, 1.08-1.73]).
 
For those previously mentioned factors, the ORs were as followed: increasing BMI (OR, 1.02 [95% CI, 1.00-1.03]), increasing TPI excluding the head, face, neck (OR, 1.32 [95% CI, 1.15-1.52]), at least 1 cardiovascular comorbidity (OR, 1.56 [95% CI, 1.28-1.90]), and emergency facility use for headache in the past 6 months (OR, 1.73 [95% CI, 1.30-2.31].

From the data, it was also revealed that men were more likely to use opioids (OR, 1.74; 95% CI, 1.38-2.20) for acute migraine treatment. However, receiving a diagnosis of migraine or chronic migraine was associated with a significantly decreased likelihood of opioid use (OR, 0.38 [95% CI, 0.30-0.48]).

“As new treatment options designed specifically to prevent and treat the often-excruciating pain and associated symptoms of migraine, the number of patients requiring pain relief through opioids will likely decrease,” said Andy Charles, MD, chair of the AHS Scientific Program Committee, in a statement. “Physicians and patients must work together to identify the most appropriate treatment plan tailored to each patient for managing this chronic and often debilitating health condition.”

Overall, Lipton and colleagues noted that the study findings reinforce the link between opioid use in migraine treatment and the increase of risk factors such as depression, anxiety and cardiovascular comorbidity. When receiving a diagnosis of migraine and developing a personalized treatment plan with a migraine specialist, many patients show great benefit from alternative and targeted treatments.

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REFERENCES
1. Schewdt TJ, Lipton RB, Friedman BW, et al. Demographics, headache characteristics, and other factors associated with opioid use in people with migraine: results from the chronic migraine epidemiology and outcomes study. Headache. 2019;59(S1):1-208. Presented at: 2019 American Headache Society Annual Meeting; July 11-14, 2019; Philadelphia, PA. Poster OR05.
2. New Research on Opioid Use in Migraine Reveals Challenges of Acute Migraine Care as Revealed in Studies to be Presented at AHS 61st Annual Scientific Meeting  [press release]. Philadelphia, PA: American Headache Society; Published July 10, 2019. americanheadachesociety.org/news/new-research-opioid-use-in-migraine-reveals-challenges-of-acute-migraine-care. Accessed July 10, 2019.