Opioid use for migraines opens door to future ED visits
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Patients with migraine who were given opioids in the ED were more likely to return to the ED in the next 6 months compared with patients who were not prescribed opioids, according to findings from single-center, retrospective cohort study.
Headache is consistently one of the top five reasons for ED visits in the United States, according to Qiujun Shao MS, a graduate teaching assistant at the College of Pharmacy at the University of Texas at Austin, and colleagues. Even so, migraine management can be challenging because ED physicians have limited time with patients and some may be unfamiliar with migraine diagnostic criteria or treatment options, according to the researchers.
“It is important to further understand the downstream impact of opioid use on future [health resource utilization] and opioid use among patients with migraine,” they wrote in Headache.
Shao and colleagues reviewed electronic health record data from 788 patients who presented to the ED at Baylor Scott & White Health in Texas with a migraine diagnosis.
According to the researchers, the average age of the patients was 44.5 years, 85.9% were women and 76.1% were white. Overall, 35.9% of the patients received one or more opioids during their index ED visit, and 34.8% of patients were classified as opioid naive — defined as having received no more than one opioid prescription in the 6-month period leading up to their index ED visit.
Shao and colleagues reported that, compared with patients with migraine who did not receive opioids at their index ED visit, those who did were significantly more likely to return to the ED, either because of migraines or other health problems. After controlling for covariates, the researchers found that opioid recipients had a higher risk for future migraine-related ED visits (HR = 1.49; 95% CI, 1.09-2.03). Patient characteristics associated with future migraine-related ED visits included prior ED visits (HR = 2.38; 95% CI, 1.23-4.58), prior opioid use (HR = 2.12; 95% CI, 1.24-3.65), being a woman (HR = 1.82; 95% CI, 1.12-2.86), hypertension (HR = 1.46; 95% CI, 1.07-2), smoking (HR = 1.45; 95% CI, 1.07-1.97) and being aged 45 to 64 years (HR = 0.68; 95% CI, 0.48-0.97).
In a subanalysis, opioid-naive patients who were prescribed opioids during their index ED visit were more likely to have future migraine-related ED visits compared with opioid-naive patients who were not prescribed opioids (HR = 2.9; 95% CI, 1.54-5.46).
“The impact of opioid use on future ED visits might be partially explained by the fact that opioid use is a risk factor for migraine chronification, and [chronic migraines] are associated with higher health care utilization than [episodic migraines],” Shao and colleagues wrote.
The findings provide “additional evidence of the association of opioids prescriptions and subsequent health resource use” and underscore “the need for optimizing migraine management in emergency settings,” according to the researchers.
Perspective
Back to TopMigraine headaches are common and can be debilitating, so it is not surprising that patients and clinicians alike aggressively address the pain that they cause. There are several highly effective medications to prevent and abort migraine headaches and several guidelines to help escalate care safely and effectively.
The study by Shao and colleagues shines a light on the no-longer-controversial issue of the use of opioids to treat migraine. Although they review their use in an ED setting, it is not recommended that opioids be used as initial or ongoing treatment for migraine headaches in any clinical situation. Unfortunately, and despite warnings from varied professional organizations and specialties, opioid use for the treatment of migraine unfortunately remains a common approach with grave clinical implications. Not only are migraine headache episodes more frequent, more severe and more treatment resistant, but the risk for developing long-term opioid use and opioid use disorder is markedly increased.
Shao and colleagues confirm in their retrospective analysis of ED visits at their institution in Texas the consequences of opioid use for migraine sufferers. In addition to the aforementioned patient-level concerns, they highlight the association between opioid use for migraine and future health care utilization. In particular, use of an opioid for migraine at an ED visit raised the risk for an additional ED visit by 50%. Of perhaps the greatest concern is that when they looked only at patients who were opioid naive (meaning they had not had an opioid prescription in the prior 6 months) use of an opioid for their migraine resulted in a nearly threefold risk for a future migraine-related ED visit in the subsequent 6 months. To be clear, this is not about extra ED visits per se, and although an extra ED visit here and there may not seem like a problem, ED crowding is a significant public health issue.
The issue raised by Shao and colleagues is that given our understanding of the limited effectiveness of opioids for migraines, nearly a third of migraine patients in this study received opioids for their headache. The significant risk for developing long-term opioid use, either due to hyperalgesia (worsening pain due to pain medication) or opioid use disorder, is not commensurate with the limited benefit. Simply stated, opioids should not be used in the vast majority of migraine sufferers.
For more information:
American Headache Society. Opioids and migraine. https://americanheadachesociety.org/news/opioids-migraine/#:~:text=Routine%20use%20of%20opioids%20for,episodic%20migraine%20to%20chronic%20migraine. Accessed March 11, 2021.
CDC. Acute migraine https://www.cdc.gov/acute-pain/migraine/index.html. Accessed March 11, 2021.
Choosing Wisely. Treating migraine headaches. Accessed March 11, 2021.
Professor and chair, department of emergency medicine
Director, division of medical toxicology at Rutgers New Jersey Medical School
Chief of ED service, University Hospital of Newark
Perspective
Back to Top
William Eggleston, PharmD, DABAT
The recent study by Shao and colleagues identified an association between using opioid medications to treat patients in the ED with migraine symptoms and an increased likelihood of future ED visits. The study also suggests that using opioids to treat migraine symptoms in the ED may increase the chance of patients using opioids in the future.
These findings are consistent with previous studies, and I agree with the authors’ conclusion that using opioids to treat patients’ migraine symptoms in the ED may increase the likelihood that patients will end up in the ED again with similar symptoms.
Additionally, Shao and colleagues’ data show a potential link between opioid use for migraine symptoms and future opioid use. We know that patients using higher doses of opioids or using opioids for longer periods of time have an increased risk for opioid use disorder (OUD). Although it is not likely that a person would develop an OUD from a single migraine treatment, it is possible that their risk would be higher in the future if they are using opioid medications more frequently. Given the availability of other effective migraine treatment options, lack of evidence that opioids are an effective migraine treatment, and the risk for future ED visits or increased opioid use, opioid medications should be avoided in most circumstances for patients with migraine symptoms.
Clinical toxicologist, SUNY Upstate Medical University
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