MDs Still Not Getting the Message About Opioids for Migraine

Damian McNamara

July 24, 2019

PHILADELPHIA — Despite the opioid epidemic, warnings from headache specialists, and advisories from medical societies, opioids continue to be overprescribed in the United States.

When researchers assessed more than 2000 migraine patients participating in the Chronic Migraine Epidemiology and Outcomes (CAMEO) study, they found that 36% used prescription opioids for acute pain relief of migraine or chronic migraine.

"Opioid use was very common and associated with elevations in markers of worse health," said lead author Richard Lipton, MD, professor of neurology, psychiatry, and behavioral sciences and the Edwin S. Lowe chair of neurology at Albert Einstein College of Medicine, New York City.

Lipton presented the findings here at the American Headache Society (AHS) Annual Meeting 2019.

Multiple Risk Factors

The study findings support the need for greater awareness and education regarding appropriate opioid use. With that in mind, the investigators set out to identify factors associated with a greater likelihood of opioids being prescribed among the CAMEO participants.

They found that patients who experienced 15 or more headache days per month, sought emergency care for migraine, or are men were among those most likely to be prescribed opioids.

"These results may help clinicians identify individuals who may use opioids to treat their migraine and offer alternative treatments," Lipton added.

This prevalence of opioid use in the CAMEO study is slightly higher than the 30% reported in the American Migraine Prevalence and Prevention (AMPP) study.

Likewise, the opioid prescription rate reported in the CAMEO study was higher than those in other studies presented at the AHS meeting, including the Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME) study. Among 8844 of its participants who had four or more migraine days per month, 24% were current opioid users, and 31% were former users.

For the current study, Lipton and his team assessed 2388 responses to a survey conducted as part of the CAMEO study. Participants reported current use of prescription medications for acute headache or whether they had them on hand.

In addition, 867 opioid users were compared with nonopioid users to identify factors associated with a stronger likelihood of opioid use.

"There were multiple, independent risk factors associated with getting an opioid script," Lipton told meeting delegates.

Table. Factors Associated With Opioid Use in Patients With Migraine

Factor Odds Ratio 95% Confidence Interval
Male sex 1.74 1.38 – 2.20
Emergency facility use for headache in past 6 months 1.73 1.30 – 2.31
15 or more headaches per month* 1.62 1.24 – 2.13
10 – 14 headaches per month* 1.37 1.02 – 1.82
Allodynia 1.39 1.14 – 1.70
Increasing TPI scores 1.32 1.15 – 1.52
*Compared to a reference rate of 0 – 4 headaches/month
TPI, total pain index


Last Resort

In addition, patients with migraines who used opioids were more likely to report one or more cardiovascular comorbidities (OR, 1.56; 95% confidence interval [CI], 1.28 – 1.90), depression (OR, I.50; 95% CI, 1.18 – 1.89), or anxiety (OR, 1.37; 95% CI, 1.08 – 1.73).

Increasing body mass index (BMI) was only slightly associated with a greater likelihood (OR, 1.02; 95% CI, 1.00 – 1.03). "For every point on the BMI scale, there is a small but significant increased risk of getting an opioid," Lipton said.

In contrast, those who had received a physician diagnosis of migraine or chronic migraine were less likely to use opioids (OR, 0.38; 95% CI, 0.30 – 0.48), "which is somewhat encouraging," Lipton added.

In addition to well-known risks associated with opioid use in a general population, use of the agents in this headache population has been associated with a transition from acute to chronic migraine. "We know use of opioids is associated with migraine progression," Lipton said.

In terms of limitations, the study was cross-sectional, so the researchers reported associations, not causation. In addition, opioid use was self-reported.

The American Headache Society states that opioids "could potentially be used" in select populations for occasional pain management, such as for the elderly and for pregnant women who avoid use of triptans or nonsteroidal anti-inflammatory drugs. The American Academy of Neurology's position paper on opioids for noncancer pain recommends that these agents only be prescribed for migraine "as a last resort."

More Education Needed

Commenting on the findings for Medscape Medical News, Jessica Ailani, MD, associate professor of neurology, MedStar Georgetown University Hospital, and director of the MedStar Georgetown Headache Center, Washington, DC, expressed extreme surprise.

"The first time I saw the data, I was horrified. Are we really still doing this?" she asked

"I was surprised, because I thought we were doing a better job of not using opioids for migraine," added Ailani, who was not associated with the current research. Ailani presented two posters at the AHS conference that were also based on CAMEO data.

Opioids can "change the brain in a way that makes it harder for us to get the allodynia and hypersensitivity to settle down," she said.

Ailani pointed out that headache specialists have been educating others about overprescribing opioids since "way before the opioid crisis." A finding that 36% of individuals with migraine use opioids "is sad when you've been involved in all this work and spreading the word, giving lectures, and speaking to primary care."

She emphasized that the research does not implicate primary care physicians.

"In a world where you are inundated with information and forced by the system to see patients quickly, it makes it really hard to make the decision fast, especially in complex disorders," Ailani said.

"You want to make the patient feel better, so you give them something you were told works really fast and works well," she added.

However, the results emphasize the need for more education.

"These data are really important, and we need to get it out there," she said. "The point is not to continue to be horrified but to look at this and say, 'Hey, all of us in healthcare, what are we doing to these patients? How are we contributing to a global problem? How can we fix it?' "

On the positive side, Ailani said this is an "exciting time" because of new migraine treatments in development, such as the small-molecule calcitonin gene–related peptide antagonists and the 5-HT1F receptor agonists. "So we're going to have other options available," she noted.

Andrew C. Charles, MD, chair of the Scientific Committee for the AHS Annual Meeting 2019 and neurologist at UCLA Medical Center in Los Angeles, California, echoed those thoughts in a statement representing the AHS' position on this issue.

"As new treatment options are 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," Charles said.

"Physicians and patients must work together to identify the most appropriate treatment tailored to each patient for managing this chronic and often debilitating health condition," he added.

The CAMEO study was funded by Allergan. The OVERCOME study was sponsored by Eli Lilly. Lipton and Ailani are both consultants for Allergan. Charles has reported no relevant financial relationships.

American Headache Society (AHS) Annual Meeting 2019: Abstract OR05. Presented July 12, 2019.

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