PainRelief.com: What are the main findings?
-Of 2,388 respondents with migraine using prescription medications as acute treatment, 36.3% reported that they currently used or kept on hand opioid medications to treat their headaches. We sought to identify factors associated with opioid treatment for migraine.
-Aspects of care seeking influence the use of opioids. People who have never received a medical diagnosis of migraine (but meet criteria on a validated questionnaire) are more likely to receive opioids. Since diagnosis is prerequisite for migraine specific medication, and opioids are not migraine specific medication, encouraging diagnosis may reduce opioid prescribing. People who are treated in the emergency department (ED) or urgent care are more likely to receive opioids. Encouraging appropriate prescribing in the ED and urgent care centers may be helpful.
-Current opioid users had many markers of more severe disease including high monthly headache frequency, more allodynia, greater headache-related burden, and poorer quality of life than nonusers. It is not clear if these markers of severe illness lead to opioid prescribing or if opioid use leads to worsening of headache. Likely both are true. We know that taking opioids leads to increases in headache frequency for example. Encouraging use of guideline based migraine care may improve these issues.
-Men were more likely than women to take opioids for their headaches. This apparent gender bias merits additional exploration.
-People with more comorbidities were more likely to receive opioids. People with CV comorbidities may be more likely to receive opioids because triptans, the most widely used acute prescription treatment for migraine, are contraindicated in people with many cardiovascular disease. Use of treatment strategies that do not carry cardiovascular risk may be helpful.
People with pain outside of the headache are more likely to get opioids. It is possible that opioids are prescribed for headache for the comorbid pain problem. In either case, use of opioids may lead to headache exacerbation.
People with anxiety or depression are more likely to get opioids. It is possible that opioid use exacerbated anxiety and depression or that opioids are prescribed in part to address anxiety in people with migraine. More appropriate management strategies for detecting and addressing these common psychiatric comorbidities could improve treatment.
PainRelief.com: What should readers take away from your report?
Response: The widespread use of opioids may contribute to the burden of migraine. Prescribers should consider options to opioids as acute treatments including the newly emerging drugs and devices.
PainRelief.com: What recommendations do you have for future research as a result of this work?
–We need longitudinal studies to determine the directionality of the relationship between opioid use and markers of severe disease.
-We need to develop intervention studies and educational programs to reduce prescribing of opioids as acute treatments for migraine and to encourage guideline based care.
PainRelief.com: Is there anything else you would like to add?
Response: This study was funded by Allergan, a company that makes onabotulinumtoxin A, a preventive treatment for migraine, and Ubrogepant, an acute treatment for migraine. I have conducted studies funded by, consulted for and received honoraria from Allergan and from many companies that make drugs or devices for migraine.
Richard B. Lipton, Dawn C. Buse, Benjamin W. Friedman, Lisa Feder, Aubrey Manack Adams, Kristina M. Fanning, Michael L. Reed, Todd J. Schwedt
Neurology Jun 2020, 10.1212/WNL.0000000000009324; DOI: 10.1212/WNL.0000000000009324
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