Medication Overuse Headache

Migraine and Opioid based medication

In February 2018 medications containing codeine will no longer be available over the counter (OTC) but will require a doctors prescription. The looming move of codeine based products to prescription only in Australia may have many headache sufferers concerned about their ability to cope, however many may be unaware that the drug that they are taking to relieve pain may be making their condition worse.

The Australian Therapeutic Goods Administration said misuse of over-the-counter codeine products contributes to severe health outcomes, including "liver damage, stomach ulceration, respiratory depression and death". An Australian study using coronial data showed there had been over 1,400 deaths in a little over a decade related to codeine use.

Many headache sufferers will still be able to access codeine based products with a doctors prescription, but the question is should they?

Repeated use of opioids such as codeine don’t prevent symptoms, and in their attempt to temporarily mask pain, cause disease progression and bad clinical outcomes, in particular the transformation to daily headache. The physiologic changes occur rapidly and can be permanent, and include decreased grey matter, release of CGRP (implicated in migraine pathogenesis), dynorphin and pro-inflammatory peptides, and activation of excitatory glutamate receptors. Opioids are pro-nociceptive, prevent reversal of migraine central sensitisation and interfere with triptan effectiveness. [1]

One study [2] showed that people who suffered episodic or occasional migraine and took narcotics or barbiturates more frequently were more likely to develop transformed migraine. That means they have increased their migraine days per month to more than 15, ‘transforming’ from episodic to chronic.

Its not just headache and migraine sufferers that need to be concerned.
Opioids have been shown to be problematic in inducing headache in many chronic pain conditions such as back pain and oncologic pain. Use of opioids in non-headache chronic pain was associated with a 20% likelihood of developing headache (including migraine) in the next 11 years, compared to only 3.1% in those not using opioid-based analgesics. [3,4]

We are sympathetic to those who have tried many different forms of pain relief and find codeine-based products to be the only thing to help. However we strongly support the move to prescription based access and hope that the broader chronic pain community is successful finding alternative avenues, both pharmaceutical and non-pharmaceutical to help reduce pain and improve outcomes for sufferers.

We are also conscious that this is only one part of a much bigger picture, both within migraine health and outside.

Inside the 'migraine bubble' factors relating to diet, sleep, and daily activities are always part of the picture, and recent research is indicating the issues run a lot deeper than many people will understand.  Through this year we will be looking more deeply into the research outside of our own neck based treatment to try and broaden the understanding of factors influencing migraine in the hope of getting the best possible result for those in our care.



References:
[1] Tepper, SJ 2012 Opioids Should not be used in Migraine Headache, 54 (S1) pp 30-34 
[2] Bigal, M.E. and Lipton, R. A. (2008) Excessive acute migraine medication use and migraine progression. Neurology, 71 (22); 1821-8.
[3] Johnson, J. L., et al. “Medication-overuse headache and opioid-induced hyperalgesia: a review of mechanisms, a neuroimmune hypothesis and a novel approach to treat- ment.” Cephalalgia 33 (2012): 52–64 
[4] Zwart, J.-A., et al. “Analgesic use: a predictor of chronic pain and medication overuse headache: The Head–HUNT Study.” Neurology 61(2) (2003): 160–164.
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