Choosing Wisely - Migraine headaches

What is a migraine?

Migraine is a very common type of headache, which can cause a lot of distress. Migraine attacks can last for hours – or even days. They can cause intense pain, nausea and vomiting. They can make you sensitive to light or noise and they can affect your life and work.

What is the problem?

Medicines specifically for migraines, and non-prescription painkillers, are the most effective migraine treatments. However, many patients with migraine continue to be offered strong painkillers, called opioids, to treat migraines. Examples of opioid painkillers available in New Zealand include codeine, tramadol, morphine, oxycodone, fentanyl and pethidine.

Why should I ask questions if I am prescribed an opioid for my migraine?

There are three main problems with using opioids for migraine:

1. They can make headaches worse

Using opioids for migraine can cause more headaches and chronic migraines than you had to begin with. This is called “medication overuse headache”. It is possible with all pain medications, but is more likely with opioids.

2. They are not as effective as other migraine medicines

There are other medicines that can reduce the number of migraines you have, and how severe they are, better than opioids. This includes medicines called triptans, which work directly on the blood vessels in your head to relieve the pain from migraine.

3. They can be harmful

Opioids are strong medications, which may cause you harm, including dependence and addiction. Opioids can cause serious withdrawal symptoms if you stop taking them suddenly. People who use high doses for a long time may need to be in the hospital in order to stop using them.

Opioids, even at low doses, can make you feel sleepy or dizzy. Other side effects include constipation and nausea. Using them for a long time can lower your sex drive and cause depression and sleep problems.

Which medicines are good for migraines?

The type of medication you need depends on many things, including how frequent and severe your migraines are. Your doctor will advise you on the best treatment, based on your symptoms and experience.

A usual approach is:

• Step 1: Non-prescription pain relievers such as paracetamol and NSAIDs (such as ibuprofen, diclofenac, naproxen).
• Step 2: Triptans (such as sumatriptan, rizatriptan or zomitriptan).
• Step 3: Combination treatment with a triptan and an NSAID.

All of these options work best if you use them when the migraine is just beginning.

Anti-sickness medicines may also be used to relieve nausea associated with migraine. Examples include metoclopramide, domperidone and prochlorperazine.

If you have migraines often, or if they are very severe, ask your doctor about other medicines to prevent headaches.

When might I need an opioid for migraine?

If you have certain medical conditions, such as some heart diseases or you are pregnant, you may not be able to take the migraine-specific medicine. Talk to your doctor if this applies to you.

In some people, the migraine-specific medicines don’t work. Opioid painkillers may be a short-term “rescue” option for these people. In this situation, you should not take opioids more than 9 days per month. At the same time, you and your doctor should continue to focus on other strategies to help you prevent and manage your migraines. Long-term follow-up is needed to make sure you do not develop complications from taking opioids.

How can I manage migraines without medicines?

Some migraines can be managed without medication. Talk to your doctor about how to:

• Avoid triggers. These are things that bring on your headaches. Common food triggers are chocolate, cheese, alcohol, foods with MSG, and meats with nitrates (such as some processed meats). Other common triggers are strong smells, bright light, skipping meals, and smoking.
• Reduce stress. Stress can bring on migraines. Try doing activities to help you relax, such as meditation, walking or swimming, yoga, tai chi, or stretching exercises. If you feel anxious or depressed, ask your doctor to help you treat these conditions or refer you to a psychiatrist for treatment.
• Get regular sleep and exercise. Too much or too little sleep can lead to migraines. Aim for seven to eight hours a night, with a regular bedtime and wake-up time. Physical activity, such as walking or swimming, can also help prevent obesity, a risk factor for migraines.
• Control symptoms. When you get a migraine, lie down in a quiet, dark room if you can. Put a cold cloth or compress over your forehead, massage your scalp, or press on your temples. Drink plenty of water, especially if you have vomited. It is helpful to take medications as early as possible.
• Keep a headache diary. This can help you figure out what your triggers are and keep track of the medicines you use. Write down:
  • When the pain began.
  • What you were doing before the pain began.
  • What you ate and drank in the 24 hours before the headache.
  • The medicine and dose you used to treat the pain and when you took it.
  • How well your headache attack responded to the medication.

For more information about migraines visit HealthNavigator.org.nz.

It’s OK to ask questions
If you have questions about your symptoms or the medicines managing your symptoms, speak with your health professional.

Supporting evidence

• Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-68.
• Evers S, Afra J, Frese A, et al. European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. Eur J Neurol [Online] 2009;16(9):968-81.
• Tepper SJ. Opioids should not be used in migraine. Headache 2012;52; S1:30-4.

Developed by Choosing Wisely New Zealand, 2018. Adapted from Choosing Wisely Canada (2015), Treating migraine headaches: some drugs should rarely be used, and Health Navigator (2017), Migraine (severe headache). Choosing Wisely does not assume any responsibility or liability arising from any error or omission or from the use of any information in these resources.