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Neurology Today: Opioids Are Not Recommended but Often Prescribed for Migraine Across All Age Groups

By Ed Susman

Although opioids are not recommended for treatment of migraine—except as a last resort—three new studies presented at the annual meeting of the American Headache Society suggest that the drugs are prescribed often to patients of all ages—ranging from 23 percent to 36.3 percent of the time—as a first-line therapy.

Those getting opioids included teens and young adults as well as predominately lower income patients, the studies found.

Jennifer Bickel, MD, FAAN, chief of the headache section and associate professor of pediatrics at Children's Mercy Kansas City/University of Missouri-Kansas City School of Medicine, was particularly concerned about the numbers of young adults and teens being prescribed opioids in emergency departments.

In an analysis of data from the Cerner Health Facts electronic health record (EHR) data warehouse, comprising of de-identified EHR data from more than 600 hospitals and clinics in the US, she and her colleagues found that 23 percent of 14,494 adolescents and young adults—ages 12 to 25—were prescribed opioids when they presented at emergency departments for treatment of migraine.

The likelihood of being treated with opioids was significantly higher for patients who were older, female, white, seen by a surgeon, and who had longer encounters and encounters earlier in the time period sampled—2010 to 2016.

Sites varied widely in the percentage of encounters involving opioids: Higher rates were associated with smaller sites with relatively higher proportions of commercially insured patients, the researchers reported.

“We need to improve the foundational knowledge of migraine treatment in all physicians who may encounter this prevalent condition—including the emergency department and urgent care facilities, primary care physicians, hospitalists, obstetricians/gynecologists, etc.,” Dr. Bickel said. “Many effective treatments exist, including pharmacological and non-pharmacological approaches. Opioids may sometimes be required in the setting of certain medical co-morbidities but only after exhausting other options under the care of a trained headache specialist.”

She said it was possible to reduce the administration of opioids in migraine when hospital teams coordinate their approaches. The rate of opioid prescription at her facility is around two percent, she said, after a few initiatives were put into place.

“In 2010, neurology and the emergency department teamed up to create evidence-based guidelines on the emergency room treatment of pediatric migraines,” Dr. Bickel said. “The guidelines were accompanied by an electronic health record order set that did not have opiates as an option for treatment. We already had low rates of opioid use but this drove the numbers down even farther.”

“In 2018, we opened the Headache Treatment Center,” Dr. Bickel continued “This is a unique care setting that allows for self-referred patients to receive headache specific abortive therapies within 48 hours by a headache trained physician or advanced practice provider. Over the past year, we have treated hundreds of kids with an intractable headache that may have otherwise gone to the emergency department.”

“From our own unpublished chart reviews, in 2014, 70 percent of children referred to our clinic for headaches had never been prescribed a medication for their headaches,” she said. “Of the 30 percent prescribed a medication, one in five was prescribed a controlled substance such as an opioid.”

Dr. Bickel told Neurology Today she has concerns that the pendulum of treatment may swing too far. “My fear is that the medical community will equate avoiding opioids with avoiding treating migraine and other pain conditions,” she said. “This cannot happen. Migraines are highly disabling and may require comprehensive treatment.”


Read the full story via Neurology Today

Learn more about the Headache Treatment Center at Children's Mercy