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Too Many Patients With Migraine Receiving Opioids, Barbiturates

Washington, DC — Inappropriate prescribing of opioids and barbiturates for the treatment of migraine is common, a new study suggests. The study is the first to examine recent statistics on opioid and barbiturate-containing medication use in patients presenting to a headache center, said Mina T. Minen, MD, MPH, director of Headache Services and assistant professor in the Department of Neurology at New York University Langone Medical Center.
"We found it surprising that despite guidelines stating that these medications are not recommended as first-line treatments for primary headache disorders, [they] are still in use by a substantial number of patients," Dr Minen told Medscape Medical News. The findings were presented here at the American Headache Society (AHS) 57th Annual Scientific Meeting.

Half With Migraine Given Opioids or Barbiturates 
Several specialty societies have issued recommendations that advise against the indiscriminate use of opioids or barbiturate medications for the treatment of migraine, instead advising triptans as first-line treatment for moderate to severe migraine and nonsteroidal anti-inflammatory drugs (NSAIDs) for milder headache pain. "Choosing Wisely" admonishments from the American Academy of Neurology and the American Headache Society relay the same message, stating bluntly, "Don't use opioid or butalbital treatment for migraine except as a last resort." Yet, when Dr Minen and colleagues surveyed 217 patients presenting to a tertiary care headache center in 2014, over half reported having been prescribed an opioid or a barbiturate-containing medication in the past, and 1 in 5 were currently using those medications.

Also surprising, she noted, was the long duration many of the patients had been receiving the medications, with a quarter reporting having been taking them for more than 2 years. The American Academy of Neurology's position paper on opioid use says that no substantial evidence supports long-term use of opioids and that it incurs serious risk of overdose, dependence, or addiction. "Thus, our results are concerning," Dr Minen said. Asked to comment, American Headache Society president Lawrence C. Newman, MD, told Medscape Medical News that the study "both surprises and dismays me."

Dr Newman, who is professor of neurology at Icahn School of Medicine at Mount Sinai and director of The Headache Institute at Mount Sinai-Roosevelt Hospital, New York, said, "We've known for years that the use of opioids and barbiturates are inappropriate for patients who suffer from migraine for a number of reasons, not the least of which is that they induce more frequent headaches if taken in excess." Dr Newman also expressed frustration that so many clinicians aren't up to date, given that the triptans have been around for 20 years. "The education is lacking somewhere," he said. "Clinicians need to be better able to diagnose migraine, and they need to realize that in the absence of contraindications the specific agents, the triptans, are the drugs of choice."

In this analysis, patients presenting to the Headache Center for care during May and June 2014 were asked to complete the anonymous one-page surveys, which asked about basic demographic information, headache diagnosis, certain medical diagnoses/headache comorbidities (stroke, heart attack, high blood pressure, depression, anxiety, and substance abuse), headache frequency, and medication history. Patients were also asked whether they thought the medications were effective; the type of provider who had given them the prescription; and, if they had stopped taking it, the reason. Of 244 patients given the survey, 217 gave complete and consistent answers. Most (79%) were female, and most (84%) had a diagnosis of migraine. More than half reported having being prescribed an opioid (55%) or a barbiturate (57%). About a fifth reported currently receiving opioids (19%) or barbiturates (21%) at the time they completed the survey.

While 25% reported taking opioids for more than 2 years, another third (32%) had been taking them for less than a week. The most common reason given for stopping the medications was that they didn't help, cited by 31% with regard to opioids and 62% for barbiturates. A third (35%) reported finding opioids effective, and two thirds (64%) said barbiturates were effective. However, Dr Minen noted, "While most found opioids or barbiturates helpful, many did not like them, were limited by side effects, or did not find them to be helpful."

Who's Doing the Prescribing?
General neurologists were the most frequent prescribers of the barbiturates (38%), while emergency medicine physicians were cited the most often by the opioid users (20%). Primary care physicians were also frequent sources for both types of medications, with internists cited as the prescribers of 22% of the barbiturates and family medicine physicians for 17.5% of the opioids. Triptans are contraindicated in patients with major cardiovascular risk factors, but just 17% of the patients reported having hypertension, only 3% reported a history of stroke, and none reported a history of heart attacks. Dr Minen noted that while triptans are contraindicated in patients with uncontrolled hypertension, they are generally considered safe if the hypertension is controlled. "Thus, it is unlikely that the explanation for why so many patients have been on these medications is because of cardiovascular contraindications."

She added that while some of the patients may have been given opioids or barbiturates as rescue medications if the first-line triptans or NSAIDs didn't work, "we still think that many of the patients were likely prescribed them inappropriately." Dr Newman told Medscape Medical News that the barbiturate medications, notably those containing butalbital, are "old, old medications that have never actually been studied for migraines. They were studied for tension headaches 50 or 60 years ago, and are the most common cause of transformation from episodic to chronic headache."
He theorized that perhaps physicians were still prescribing the older drugs "because they're easy — you don't have to make the diagnosis of migraine, you're just giving a symptomatic treatment. You're not helping the patient in the long run…it's just giving a quick fix."

Also "upsetting," he said, is that each of the subspecialties identified in the survey — including emergency medicine — has guidelines on the proper use of these medications, yet they're not being heeded.
"There are evidence-based guidelines and it is important to be aware of them," Dr Minen concluded.
Dr Minen has disclosed no relevant financial relationships. Dr Newman is an advisor for TEVA and Lilly.

American Headache Society (AHS) 57th Annual Scientific Meeting. Abstract PF01. Presented June 19, 2015. Ref:

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