What are opioids?

Opioids are painkillers. They act on natural morphine receptors in the brain. Opium, extracted from the poppy plant, is a natural opioid. There are many different synthetic opioids. 

NameBrandEquivalent of morphine dose
MorphineStatex1
CodeineEmpracet (with acetaminophen)0.15
OxycodoneSupeudol1.5
HydromorphoneDilaudid5
MeperidineDemerol0.1
FentanylFentanylSpecial chart needed
MethadoneMetadolNot reliable
TramadolTramacet (with acetaminophen)Not reliable
BuprenorphineButrans


See: https://www.cdc.gov/drugoverdose/pdf/calculating_total_daily_dose-a.pdf


I thought that opioids were very effective to treat pain!

That is correct. They are a major advance of modern medicine. For acute pain, nothing works as good as opioids. But on the long term, they have side effects and risks. Those risks include tolerance (the opioids become less and less effective), addiction (the person takes opioids and becomes dependent, beyond the use for pain), constipation, bone problems. The regular intake of opioids is associated with car accidents, hip fractures and problems with newborn kids if the mother is using. 

What is the «opioid epidemic»?

In the 1990s, pharmaceutical companies convinced medical experts to advocate for an extensive use of opioids to treat chronic pain. The benefits were overestimated and the risks ignored. Physicians changed their prescription habits. A black market of prescription opioids got settled. Now North America is suffering the consequences of too many opioids, including deaths. 

Why is it so important to avoid opioids for migraine?

The migraine brain has a special chemical software. Unfortunately, it reacts to the regular exposure to opioids by changing his reaction to pain and lowering the migraine threshold. In a nutshell, opioids relieve pain on the short term, but decrease tolerance to pain on the long term. There is a very high risk of medication overuse headache with opioids.

If you end up using them on 10 days a month or more, it is clearly time to talk to your doctor about other alternatives for you migraine.

People with migraine should be aware that some combination analgesics in Canada that are available without a prescription do contain small amounts of codeine, and the above recommendations apply to those as well.

Canadian Fact on opioids: over-the-counter access puts the population at risk

In many countries, especially in Europe, opioids are not available without a medical prescription. In Canada, combination analgesics may contain smaller doses of codeine. Tylenol 1s and 2s are in this category. The dose in one pill might be low, but many patients may end up using multiple tablets per day on a regular basis. 

Read more about the opioid crisis in Canada.

Opioids work for me, they seem to be my only option. What should I do?

Medical guidelines for migraine attacks recommend that NSAIDs (anti-inflammatories) and triptans should be used first (See this post). They work usually better than opioids. This being said, some people cannot use triptans (history of vascular problems) or NSAIDs (gastro-intestinal problems). These people may try opioids to treat their migraines. Also, some people do not respond to any triptan (we remind that many triptans should be tried before making that conclusion, as the response varies a lot between people). In any case, some people do use opioids to treat migraine attacks, but this should be monitored by a skilled health care provider to avoid complications. 

REFERENCES

Tepper SJ. Opioids should not be used in migraine. Headache. 2012;52 Suppl 1:30-4.

Buse DC, Pearlman SH, Reed ML, Serrano D, Ng-Mak DS, Lipton RB. Opioid use and dependence among persons with migraine: results of the AMPP study. Headache. 2012;52(1):18-36.

Saper JR, Lake AE, 3rd, Bain PA, Stillman MJ, Rothrock JF, Mathew NT, et al. A practice guide for continuous opioid therapy for refractory daily headache: patient selection, physician requirements, and treatment monitoring. Headache. 2010;50(7):1175-93.

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