The use of
opioids in
headache treatment is very controversial. In the
migraine acute attack use of short-acting
opioids is not recommended by the principal guidelines but is frequent in North American emergency departments. Their efficacy in
migraine acute attack has not been extensively studied but seems to be similar to non-steroidal anti-inflammatory drugs and
metoclopramide.
Opioids have been never compared to
triptans. The principal concerns about the use of
opioids regard the possible association with an increased risk of
medication-overuse headache and chronic
migraine and the risk of abuse and dependence. These risks have to be considered but not overestimated. The association between frequent use and increased risk of chronic
migraine has been observed for almost all categories of acute
migraine attack drugs. Compared to the reference category of
acetaminophen, risk of chronic
migraine for
opioid use is only moderately higher (with an OR = 1.48). In some cases, when treatment with
triptans, non-steroidal anti-inflammatory drugs, or
ergotamines is contraindicated or simply ineffective, a judicious prescription of a short-acting
opioid for severe
migraine attacks can be considered. Chronic
migraine is a highly disabling condition. Although the options for prophylaxis
therapy of
migraine have expanded and improved considerably over recent years, chronic
migraine remains very difficult to treat. The results coming from small clinical series are described, suggesting that in expert hands daily long-acting
opioids provide an option for the treatment of some individuals with chronic
intractable headaches.