Opioid Medications and Migraine

Created 04-18-2009

Migraine patients who used opioid medications first have been found to have a less effective triptan response than those who did not use opioids. This was consistently found in seven different studies of rizatriptan (Maxalt®). The study authors concluded that, based on these results, recommendations to use triptans as first-line treatment rather than opioids are confirmed.

The authors reviewed seven studies of rizatriptan that had been done in order to assess the medication for safety and effectiveness prior to submission to the US Food and Drug Administration for approval. (These are called phase 3 studies.) In all seven of these studies, subjects were instructed to wait and treat attacks that were moderate to severe. Altogether, there were over 2000 individuals in these studies who received the active drug, rizatriptan, and not placebo. (In some studies, both rizatriptan and sumatriptan were compared to placebo, but this did not affect the results reported here.)

In addition, the authors reviewed the results of two studies designed to look at the early treatment of migraine. Subjects generally treated a mild migraine with rizatriptan in these studies.

Recent prior opioid use was based on medication use reported in the 30 days previous to the study. About 13% of subjects in the moderate-to-severe migraine treatment studies and about 5% of the subjects in the early treatment migraine studies reported recent use of opioid medications.

There were fewer study subjects who had recent prior opioid use that achieved pain freedom at the two-hour mark than those who had not used opioids.

This data is retrospective—a look back at the information, and this is never as powerful as what we call a prospective study. But, as the authors of this study comment, this does suggest that a prospective study would be useful to gain further insight into the effect of opioids on the effectiveness of triptans in the treatment of migraine attacks.

reference:  Ho, T, Rodgers, A, Bigal, M. Impact of recent prior opioid use on rizatriptan efficacy. A post hoc pooled analysis. Headache. 2009;49(3):395-403.

By Christina Peterson, MD