Risks of Opioid Use in Migraine Go Beyond Potential Abuse

CONFERENCE REPORTER

The use of opioids in patients with migraine is common but carries a high degree of risk. Presenters at the American Headache Society 61st Annual Scientific Meeting, held July 11–14 in Philadelphia, addressed various aspects of this growing problem.

More acute medication overuse

Todd Schwedt, MD, Associate Professor of Neurology at the Mayo Clinic in Phoenix, AZ, participated in the MAST Study of adults with migraine, in which respondents with acute medication overuse (AMO) were significantly more likely to be taking triptans, opioids, barbiturates, and ergot alkaloids and significantly less likely to be taking NSAIDs than those not overusing medications. AMO was associated with higher symptom severity scores, pain intensity, and rates of cutaneous allodynia.

Earlier, Dr Schwedt and coauthors advised encouraging patients with migraine to obtain migraine pain treatment early and avoid overuse of medications. They recommended considering infrequent use of opioids or acetaminophen in combination with codeine or tramadol as part of the “back‐up plan” when the initial treatment does not provide meaningful and sustained benefits.

Increases in opioid abuse and opioid-related deaths

Sait Ashina, MD, Assistant Professor of Neurology, Beth Israel Deaconess Medical Center, Brookline, MA, coauthored a commentary, “Pain: What We Have Achieved in the Past 25 Years,” that described advances in understanding of pain and new agents for the treatment of acute and chronic pain. Well-selected patients have benefited from opioids, it was noted, but a rise in the prescription of opioids has resulted in increases in prescription opioid abuse and opioid-related deaths. Clinicians are becoming better educated on how to manage pain with opioids and monitor for and treat addiction, and abuse-deterrent opioid formulations are becoming more available.

In another commentary, Dr Ashina suggested that the use of opioids in the treatment of headache has been limited, especially because of the availability of conventional therapies for migraine and concerns about overuse and possible adverse effects, but opioids use can result in headache reduction and functional improvement in some patients.

Reducing unwarranted opioid exposure in youth

Jennifer Bickel, MD, Neurologist and Medical Director of the Headache Program at Children's Mercy Hospital and Clinics in Kansas City, MO, and coauthors recently conducted a study to evaluate opioids used for treating migraine in adolescents and young adults in emergency care settings. The likelihood of being treated with opioids was significantly higher for patients who were older, female, white, and seen by a surgeon and who had longer and earlier encounters. Higher rates of encounters involving opioids were associated with smaller sites that had relatively higher proportions of commercially insured patients. The authors suggested that the findings “may be helpful for benchmarking and informing quality improvement efforts aimed at reducing unwarranted opioid exposure in youth.”

Other opioid studies

In another recent study, nonpersistence with prophylactic treatment was observed in 90% of patients with migraine. Of those patients, 39% switched, 30% restarted, and 31% discontinued treatment. Opioid use was common-77.4% of patients received opioids over the follow-up. Among opioid users, the risk of gastrointestinal adverse events and abuse increased with long-term use, which suggests a need for more effective prophylactic migraine treatments.

A commentary that described risk factors and behavioral issues in opioid treatment for migraine suggested that opioids be used sparingly and exclusively in conjunction with comprehensive assessment and integration of psychological treatment. “Psychological comorbidities, cognitive constructs, and behavioral responses to pain greatly impact the perception of migraine pain, treatment efficacy and outcome, and overall quality of life and functioning,” it was noted. “Current considerations for migraine treatment emphasize the utility of the biopsychosocial model in understanding and treating migraine, noting both the importance of addressing psychological factors such as cognitive beliefs as well as psychiatric comorbidities.”

Review authors suggested another reason to avoid opioids in headache and migraine treatment-opioids are overused because physicians may be unfamiliar with drug interactions between opioids and other medications, especially the possibility of serotonin toxicity. The potential for serotonin syndrome is relatively high in patients who are using opioids for pain control, they noted.

References:

1. Global Leaders in Migraine Research to Convene at The American Headache Society 61st Annual Scientific Meeting [press release]. Mount Royal, NJ: American Headache Society. July 8, 2019. Accessed July 9, 2019.

2. Schwedt TJ, Alam A, Reed ML, et al. Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study. J HeadachePain. 2018;19:38. doi: 10.1186/s10194-018-0865-z.

3. Pringsheim T, Davenport WJ, Marmura M, et al. How to apply the AHS evidence assessment of the acute treatment of migraine in adults to your patient with migraine. Headache. 2016;56:1194-1200. doi: 10.1111/head.12870. Epub 2016 Jun 20.

4. Ashina S, Sackheim K, Gharibo C. Pain: what we have achieved in the past 25 years. Neurology Reviews. 2018;26:17-18.

5. Ashina S. Opioid analgesic use during pregnancy: commentary by Sait Ashina, MD. Neurology Reviews. 2011;19:34.

6. Connelly M, Glynn EF, Hoffman MA, Bickel J. Rates and predictors of using opioids in the emergency department to treat migraine in adolescents and young adults. Pediatr Emerg Care. 2019 Jun 22. doi: 10.1097/PEC.0000000000001851. [Epub ahead of print]

7. Bonafede M, Wilson K, Xue F. Long-term treatment patterns of prophylactic and acute migraine medications and incidence of opioid-related adverse events in patients with migraine. Cephalalgia. 2019 Feb 28:333102419835465. doi: 10.1177/0333102419835465. [Epub ahead of print]

8. Stone MT, Weed V, Kulich RJ. Opioid treatment of migraine: risk factors and behavioral issues. Curr Pain Headache Rep. 2016;20:51. doi: 10.1007/s11916-016-0581-9.

9. Ansari H, Kouti L. Drug interaction and serotonin toxicity with opioid use: another reason to avoid opioids in headache and migraine treatment. Curr Pain Headache Rep. 2016;20:50. doi: 10.1007/s11916-016-0579-3.