Among patients with migraine who use prescription medications, the increasing use of prescription opioids is associated with chronic migraine, more severe disability, and anxiety and depression, according to an analysis published in the January issue of Headache . The use of prescription opioids also is associated with treatment-related variables such as poor acute treatment optimization and treatment in a pain clinic. The results indicate the continued need to educate patients and clinicians about the potential risks of opioids for migraineurs, according to the researchers.
Dr. Richard Lipton
In the Migraine in America Symptoms and Treatment (MAST) study, which the researchers analyzed for their investigation, one-third of migraineurs who use acute prescriptions reported using opioids. Among opioid users, 42% took opioids on 4 or more days per month. “These findings are like [those of] a previous report from the American Migraine Prevalence and Prevention study and more recent findings from the Observational Survey of the Epidemiology, Treatment, and Care of Migraine (OVERCOME) study,” said Richard Lipton, MD, Edwin S. Lowe professor and vice chair of neurology at Albert Einstein College of Medicine in the Bronx, New York. “High rates of opioid use are problematic because opioid use is associated with worsening of migraine over time.”
Opioids remain in widespread use for migraine, even though guidelines recommend against this treatment. Among migraineurs, opioid use is associated with more severe headache-related disability and greater use of health care resources. Opioid use also increases the risk of progressing from episodic migraine to chronic migraine.
A review of MAST data
Dr. Lipton and colleagues set out to identify the variables associated with the frequency of opioid use in people with migraine. Among the variables that they sought to examine were demographic characteristics, comorbidities, headache characteristics, medication use, and patterns of health care use. Dr. Lipton’s group hypothesized that migraine-related severity and burden would increase with increasing frequency of opioid use.
To conduct their research, the investigators examined data from the MAST study, a nationwide sample of American adults with migraine. They focused specifically on participants who reported receiving prescription acute medications. Participants eligible for this analysis reported 3 or more headache days in the previous 3 months and at least 1 monthly headache day in the previous month. In all, 15,133 participants met these criteria.
Dr. Lipton and colleagues categorized participants into four groups based on their frequency of opioid use. The groups had no opioid use, 3 or fewer monthly days of opioid use, 4 to 9 monthly days of opioid use, and 10 or more days of monthly opioid use. The last category is consistent with the International Classification of Headache Disorders-3 criteria for overuse of opioids in migraine.
At baseline, MAST participants provided information about variables such as gender, age, marital status, smoking status, education, and income. Participants also reported how many times in the previous 6 months they had visited a primary care doctor, a neurologist, a headache specialist, or a pain specialist. Dr. Lipton’s group calculated monthly headache days using the number of days during the previous 3 months affected by headache. The Migraine Disability Assessment (MIDAS) questionnaire was used to measure headache-related disability. The four-item Patient Health Questionnaire (PHQ-4) was used to screen for anxiety and depression, and the Migraine Treatment Optimization Questionnaire (mTOQ-4) evaluated participants’ treatment optimization.