In the United States and abroad, migraine is a significant medical problem without a standardized first line of treatment. In addition, medications are often inconsistently prescribed and can have wildly variable effectiveness. In general, there are three categories of migraine drugs:
- Prevention or prophylaxis: These medications are intended to be taken regularly (often daily) in order to prevent migraine attacks from happening
- Acute or abortive: Patients take these at the beginning of an attack when they begin to experience migraine symptoms; they are designed to halt the attack or reduce the pain.
- Rescue: When all else fails, these are utilized to break a migraine attack or when acute medications cannot be taken.
And recently, researchers explored how often people with migraine are prescribed certain medications as part of their medical care, and they came to two very interesting conclusions.
#1—Opioid drugs are frequently overprescribed for migraine
Opioids are powerful narcotic agents that are designed to reduce pain with common examples being codeine or hydrocodone. According to this latest analysis, approximately 15% of all patients were given opioids as treatment for their migraine attacks. Although it may not sound like a large percentage, patients were prescribed at the same rate as other acute medications—notably triptans. In addition, nearly 40% of people were not given any abortive migraine medication at all.1 Amazingly, in another study, three out of every four individuals who were given a prescription for opioids were not given any other acute or abortive medication in the treatment of their headache disorder.2
Experts and headache specialists continue to emphasize that opioids for migraine are not designed as a first-line treatment—in spite of the fact that it is commonly supplied in the emergency room (either as an abortive or rescue option) to reduce migraine symptoms. In fact, that number may be as high as 50% of patients who visit the emergency department.3 The fact is narcotic-based treatments are not as effective as other acute medications and have more adverse or negative side effects, regardless of when they are prescribed. There may be some merit to considering them as a ‘rescue’ option, but even that is highly debatable. Furthermore, other treatments and medications may become less effective when introduced to a system after opioids have been taken. Issues of opioid dependence and abuse as well as rebound headaches are real concerns for patients and doctors, especially given that it can increase the risk of developing chronic migraine. Disability as well as anxiety and other emotional concerns are also associated with opioid dependence.4
#2—Prevention alternatives are often overlooked in migraine treatment
The other significant finding of this latest study centers around the use of migraine preventative treatments. More than 40% of patients did not receive a SINGLE prophylactic treatment for their migraine attacks. That is truly stunning, but unfortunately other studies have supported these conclusions. For instance, researchers have suggested that approximately 3% to 13% of the millions of migraine sufferers are utilizing preventative therapies even though more may actually be eligible.5 Patients may also be unaware of alternative migraine treatments that can reduce the frequency of attacks, and may even abandon them shortly after beginning the regimen if they are not perceived as successful. Consequently, acute symptom relief tends to be the primary focus of patients and medical professionals alike in the treatment of migraine, even when prevention could be successful.
Tips for migraine treatment
Clearly, there is opportunity for both patients and doctors to get on the same page as it relates to treating migraine. A few simple suggestions include:
Discuss any and all medications with your doctor. Ask about the expected effectiveness and side effects of any suggested drugs. Arm yourself with knowledge about as many potential treatment options as you can. Print copies of the data or resources you find if it helps you remember information. Many treatments will offer research references which you can provide to your physician or specialist, who can then review to determine whether it is a valid solution. Regardless, ask plenty of questions and don’t be afraid to voice any concerns you may have.
Don't forget about prevention. There are numerous drug and non-drug prevention treatments for migraine. These range from physical products to behavioral changes and trigger management. Document known migraine triggers and work with your doctor to address what may be causing your pain.
Exercise responsibility with opioids. If an opioid is determined to be an appropriate treatment option, be certain to use it responsibly. The National Headache Foundation has some general recommendations for opioids, such as:
- Discuss and prepare for potential side effects with your doctor
- Only take them as directed and do not increase the dosage or frequency without approval
- Do not take the medication for longer than instructed
- Confirm with your doctor prior to ending opioid-based treatment
Your doctor's recommendations should trump all else—if you have any reason to doubt whether his or her decision is correct for you, do not decide to try something else on your own. Simply ask more probative questions or consider seeking a second opinion.
Develop an ER plan. Have a plan if you need to visit the emergency room for a migraine attack. This can include who to contact, what hospital you prefer to visit, documents of your medical history (including known allergies and prior treatment history), and knowing how to handle suggested medications. Write it down in case the pain is too severe to remember everything, and share it with whoever is most likely to take you to the hospital if you are unable to make it on your own.
1 Charleston Iv L, Burke JF. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia. 2017 Jan 1:333102417716933. doi: 10.1177/0333102417716933. [Epub ahead of print].
2 Najjar M, Hall T, Estupinan B. Metoclopramide for Acute Migraine Treatment in the Emergency Department: An Effective Alternative to Opioids. Muacevic A, Adler JR, eds. Cureus. 2017;9(4):e1181. doi:10.7759/cureus.1181.
3 Brauser D. Prochlorperazine Twice as Effective as Opioid Hydromorphone for Acute Migraine in EDs. 2017 Jun 16. Retrieved from http://www.medscape.com/viewarticle/881723.
4 Gelfand AA, Goadsby PJ. A Neurologist’s Guide to Acute Migraine Therapy in the Emergency Room. The Neurohospitalist. 2012;2(2):51-59. doi:10.1177/1941874412439583.
5 Estemalik E, Tepper S. Preventive treatment in migraine and the new US guidelines. Neuropsychiatric Disease and Treatment. 2013;9:709-720. doi:10.2147/NDT.S33769.