Opioids, such as hydrocodone, and barbiturates, such as butalbital, are still being used in headache patients despite strong evidence that they have problematic side effects. Headache experts agree that they should not be used as first-line treatment of migraine. Rather, triptans, such as sumatriptan, are the drugs of first choice.

Depression and anxiety are common in migraine, and these patients experience less pain relief from opioids and are probably at increased risk to develop drug dependence. Chronic use of prescription opioids raises the risk of death. Patients who use both opioids and sedatives, such as butalbital, have the highest risk of fatal overdoses.

Now, a study from several headache centers found that more than half of the patients had been prescribed an opioid or a barbiturate. About a fifth were on one or the other class of drugs at the time they were first seen. Twenty-five percent had been on opioids for more than 2 years. The reasons that patients stopped opioids were that they did not help in about 30% or that they saw a new doctor who would not prescribe them, also 30%. Of the patients who stopped barbiturates, about two-thirds did so because it was not helpful, and about 18% saw a new doctor who would not prescribe them.

The speciality that was most frequently cited as being the first prescriber for opioids was emergency department physicians. Family doctors and general neurologists were the next groups. General neurologists were the most frequent first prescribers of barbiturates.

There is clearly a need for better physician education.

See Headache, October 2015, page 1183.

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