Article In Brief
Three different studies documented use of opioids for managing migraines and the challenges ahead in suggesting alternative therapies.
PHILADELPHIA—Although opioids are not recommended for treatment of migraine—except as a last resort—three new studies presented here at the annual meeting of the American Headache Society suggest that the drugs are prescribed often to patients of all ages—ranging from 23 percent to 36.3 percent of the time—as a first-line therapy.
Those getting opioids included teens and young adults as well as predominately lower income patients, the studies found.
And while migraine specialists interviewed by Neurology Today agreed that the number of opioid users may have declined in the last two years, much more could be done to educate physicians and patients about other treatment options and to focus research around acute migraine care.
Opioids for Young Adults and Teens
Jennifer Bickel, MD, FAAN, chief of the headache section and associate professor of pediatrics at Children's Mercy Kansas City/University of Missouri-Kansas City School of Medicine, was particularly concerned about the numbers of young adults and teens being prescribed opioids in emergency departments.
In an analysis of data from the Cerner Health Facts electronic health record (EHR) data warehouse, comprising of de-identified EHR data from more than 600 hospitals and clinics in the US, she and her colleagues found that 23 percent of 14,494 adolescents and young adults—ages 12 to 25—were prescribed opioids when they presented at emergency departments for treatment of migraine.
The likelihood of being treated with opioids was significantly higher for patients who were older, female, white, seen by a surgeon, and who had longer encounters and encounters earlier in the time period sampled—2010 to 2016.
Sites varied widely in the percentage of encounters involving opioids: Higher rates were associated with smaller sites with relatively higher proportions of commercially insured patients, the researchers reported.
“We need to improve the foundational knowledge of migraine treatment in all physicians who may encounter this prevalent condition—including the emergency department and urgent care facilities, primary care physicians, hospitalists, obstetricians/gynecologists, etc.,” Dr. Bickel said. “Many effective treatments exist, including pharmacological and non-pharmacological approaches. Opioids may sometimes be required in the setting of certain medical co-morbidities but only after exhausting other options under the care of a trained headache specialist.”
She said it was possible to reduce the administration of opioids in migraine when hospital teams coordinate their approaches. The rate of opioid prescription at her facility is around two percent, she said, after a few initiatives were put into place.
“In 2010, neurology and the emergency department teamed up to create evidence-based guidelines on the emergency room treatment of pediatric migraines,” Dr. Bickel said. “The guidelines were accompanied by an electronic health record order set that did not have opiates as an option for treatment. We already had low rates of opioid use but this drove the numbers down even farther.”
“In 2018, we opened the Headache Treatment Center,” Dr. Bickel continued “This is a unique care setting that allows for self-referred patients to receive headache specific abortive therapies within 48 hours by a headache trained physician or advanced practice provider. Over the past year, we have treated hundreds of kids with an intractable headache that may have otherwise gone to the emergency department.”
“From our own unpublished chart reviews, in 2014, 70 percent of children referred to our clinic for headaches had never been prescribed a medication for their headaches,” she said. “Of the 30 percent prescribed a medication, one in five was prescribed a controlled substance such as an opioid.”
Dr. Bickel told Neurology Today she has concerns that the pendulum of treatment may swing too far. “My fear is that the medical community will equate avoiding opioids with avoiding treating migraine and other pain conditions,” she said. “This cannot happen. Migraines are highly disabling and may require comprehensive treatment.”
The Demographics of Who Is Receiving Opioids
In another analysis, investigators delved more deeply into who was getting opioid prescriptions. Richard B. Lipton, MD, FAAN, professor of neurology, of psychiatry and behavioral sciences and of epidemiology and population health at the Albert Einstein College of Medicine, described responses from the CaMEO Study, a web-based longitudinal study of the United States population designed to characterize the course of treatment for people with episodic and chronic migraine. He said the objective of the CaMEO study was to identify variables associated with opioid use among people who received prescriptions for acute migraine attacks.
The investigators reported that of 2,388 active prescription users with migraine, 867 or 36.3 percent of them were using prescription opioids.
Certain factors were associated with a higher likelihood of having an opioid prescription for treatment of migraine: being male, unemployed, have a lower education level defined as having less than a four-year college degree, a higher body mass index, and a lower annual income—less than $30,000 a year.
Dr. Lipton noted that the study was subject to several limitations, not the least of which was that self-reporting may have introduced participation bias into the research.
Conditions for Opioids Use
Finally, in the so-called OVERCOME study, another web-based survey sponsored by Eli Lilly and Company, Sait Ashina, MD, assistant professor of neurology and anesthesia at Harvard Medical School, and director of the Comprehensive Headache Center, Beth Israel Deaconess Medical Center in Boston, looked at the patterns of opioid use among migraine patients.
“Previous population-based studies had found it to be common with negative consequences, including higher health care costs for patients with migraine and a higher risk of progression from episodic to chronic migraine. They also found more severe headache-related disability, symptomology, co-morbidities, and greater health care resource utilization for headache,” Dr. Ashina said in his oral presentation.
Dr. Ashina and his colleagues mined data from a cohort of 21,143 people with migraine to better understand those with the greatest care needs. They grouped people according to their self-reported opioid use for migraine: current, former, or never used.
Among their findings, 19 percent of the patients in the cohort reported that they were currently taking opioids, 28 percent they had previously taken prescribed opioids for their headaches, and 53 percent had never taken opioids for migraine.
Of the 8,844 patients who experienced four or more headache days a month, 24 percent said they were currently using opioids, and 31 percent said they were former opioid users, while 45 percent said they never used opioids.
The researchers said the likelihood of patients with four or more headaches days a month using opioids increased if they also had chronic low back pain; chronic neck pain; fibromyalgia; osteoarthritis; anxiety; depression; 15 or more headache days a month; or if they had moderate or severe migraine rather than little or mild migraine disability.
Dr. Ashina noted that as a self-reported survey the findings were limited to recall and selection bias. Nevertheless, he said, “Current opioid use remains high among people with migraine, which underscores the need for improvements in migraine care. Future researchers should consider additional influences on opioid use, such as associated migraine symptoms, triptan use, and preventive medicine use.”
Commenting on the studies, Jessica Ailani, MD, director of the MedStar Georgetown Headache Center and associate professor of neurology at Georgetown University Hospital Pasquerilla Healthcare Center in Washington, DC, said the fact that several abstracts at the AHS meeting reported that opioids continue to be the number one treatment for migraine patients indicates that “the opioid epidemic seems to be far from over as it relates to treatment in migraine.”
“While these studies are looking back, and it is possible things have been changing in the last two years, I believe the problem stems from two big issues—lack of education on what to use to acutely treat migraine when the standard of care (triptans) has failed or is contraindicated and lack of education about ergots and how to use them, as well as anti-dopamine agents.”
“Not enough acute migraine treatment options are available to meet the variety of patients who need them,” she added. “Triptans work for many patients, but not all, and are not a good option in patients who have cardiovascular risk or are older. They don't work great if a patient is one to two days into a severe migraine attack which typically is when patients go to the emergency room.”
Dr. Ailani was particularly disturbed that children are receiving opioid prescriptions. “Again, I think the issue is lack of education as well as not enough acute treatment options that are well studied in children for migraine.”
“The education part can be solved,” she said, by mandating that physicians have CME credits on acute treatments in migraine, to be completed when their license renewal is due.”
She said that in the Maryland/DC region, “we have one to three CME credits per two years that has to be from pain management/opioid use to ensure we are all obtaining some information on appropriate use of these medications. I think it would be fair to require the same for migraine as every practice in medicine is bound to see patients with migraine. This requirement can help reduce opioid and butalbital use for migraine and can make large strides in reducing inappropriate care for these patients.”
Noah Rosen, MD, director of Northwell Health's Headache Center, and associate professor and program director of neurology at the Zucker School of Medicine at Northwell Health in Great Neck, NY, said that much of the risk of chronic opiate misuse may stem from early, unnecessary exposure to opiates an a lack of formal education or structure that comes with their use.
“As the abstract [by Dr. Bickel and colleagues] shows, there is a high rate of non-standard of care use of opiates in the pediatric population in emergency rooms. This is a setting that often does allow for the time for adequate education let alone regular monitoring.”
Dr. Rosen suggested there are ways to reduce opioid use in the emergency department. “Recognizing primary headache disorders and distinguishing them from secondary headaches allows for appropriate use of more specific, lower risk medications,” he said.
“Utilizing standard of care treatments like intravenous antiemetics or anti-inflammatories reduce rates of recurrence, overuse and dependence,” Dr. Rosen said.
“Recognizing and appropriately treating these conditions early is paramount to success to avoid inappropriate emergency room use and less monitored management.”
Dr. Bickel had no relevant disclosures. Dr. Ashina disclosed relationships with Allergan, Amgen, Eli Lilly and Company, Promius and Vedanta. Dr. Rosen disclosed relevant relationships with Eli Lilly, Alder, and Teva. Dr. Ailani disclosed relationships with Alder, Amgen, Allergan, electroCore, Eli Lilly and Company, Promius, Teva, Impel, Supernus, Satsuma, Alpha Sites Consulting, Neurodiem, Miller Communications, Avent, Peer View, and Biohaven.