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Which Long Term Treatment for Migraines is More Effective for Pain in Adult Patients,

Opioid or Non-Opioid

Name

University

Course Code and Name

Professor Bregman

Due Date
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Abstract

Migraines is a prevalent issue affecting thousands of people worldwide. In the United States, it is

responsible for over 1.2 million visits to the emergency departments. Despite the myriad

treatment options available, there is no standard medication for the treatment of migraines. For

the patients they brought to the emergency departments, most patients are treated using the

opioids based medications. There are other forms of medication available. Numerous scholars

have explored the available medication options in the quest to ascertain the most effective type

of pharmacology medication. The choice of medication is determined by various factors, such as

the nature of the disease, severity, cultural factors, and the type of migraines. The aim of this

paper is to review the available literature on the types of medications available for the treatment

migraines and the impacts on the patients’ outcomes. The results show that despite opioid

medication being the preferred choice, it is not the ideal form of medication. Other forms of

pharmacology treatments, such as metoclopramide, prochlorperazine, and ergots among others

are the most effective form of medication.

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PICOT - Migraines

Introduction

Migraines refer to severe, recurrent, and painful headaches, affecting an individual. The

treatment of migraines is geared towards reducing the symptoms of migraines and, at the same

time, prevention of future occurrences. There are various medications that have been developed

with the efforts of dealing with the condition. One such medication is the opioid-based and non-

opioid medication. Despite their popularity, there is a need for detailed study in the quest to gain

insights to ascertain their effectiveness. This paper is, therefore, a literature review that is geared

towards understanding past studies on the topic and identify gaps for future studies.

Literature Review

There is growing data over the last years, demonstrating that over the past years, there is

a rise in the abuse of opioid prescriptions in the U.S. The number of reported deaths, as a result,

opioid overdose is estimated to be 2-4% among adolescents. Studies have shown that exposure to

prescribed opioid medication increases the possibilities of future opioid misuse by a third. This is

an indication that opioid prescription increases the possibility for the youths to indulge in future

opioid misuse. There is a need to map the patterns of involuntary opioid exposure in youths in

the quest to address the issue as a public health emergency. One of the issues that precipitate the

use of opioids as a prescription is migraines amongst adolescents. Migraines are a common issue

amongst the youths as 1 in 10 youths have been to emergency visits. One of the most prevalent

medications that is prescribed is opioid-based medication (Connelly et al., 2019).

Connelly et al., 2019 sought to ascertain the level and situations in which opioids are

utilized in the treatment of migraines in emergency settings. The study employed data from

2010-2016 from the Cerner Health Facts that is an electronics health data record. The data was
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processed using multilevel logistic regression in the quest to determine the possibility of opioids

being used as the primary intervention medication for the treatment of migraines. The data was

then analyzed to determine the variations in the likelihood of particular sex and age groups being

treated with an opioid for migraines. The study found that the likelihood increases for older,

females, white seen by surgeons who had treated such conditions. The study notes a high

prevalence rate of opioid being used as a medication for migraines treatment amongst the youths.

However, despite the fact that the study demonstrated a high prevalence in the use of opioids in

the interventions of migraines, it fails to demonstrate the effectiveness of this intervention. There

is a need for additional studies to ascertain the efficacy of the opioid medications on the target

groups (Connelly et al., 2019).

In another study, Dodson et al. (2018) sought to ascertain the effectiveness of opioid

medication for interventions on migraines in the ED. This is a qualitative literature review that

sought to ascertain the effectiveness of opioid medications as compared to other alternatives. The

review notes that migraine is a prevalent condition affecting thousands of people, with over 1.2

million visits annually with large social and economic impacts on the population (Dodson et al.,

2018). Opioid medications have been the main medication used in migraines interventions in the

ED. The literature revealed that dopamine receptor antagonists, such as metoclopramide and

prochlorperazine, are effective interventions on migraines. Whereas the working of the drugs is

not completely understood, it is hypothesized to work by inhibiting trigeminovascular activation.

The review reveals that metoclopramide is an ideal intervention in the treatment of migraines as

it has subtle side effects. The common one is a dystonic reaction that is rare with reported cases

being one in every 500 intervention cases. Since headache is a common condition that leads to

emergency visits, the adoption of alternative medication rather than opioids would prevent its
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adverse impacts. The study calls for the balancing effects whereby the benefits of the

interventions ought to be balanced with the adverse effects brought about by the intervention. In

spite of the findings, there is a need to compare the two drugs side by side in the quest to

determine their effectiveness in the intervention. Also, there is a need to compare them with

others in the quest to ascertain their overall effectiveness and compare the side effects against

others (Dodson et al., 2018).

In yet another study, Ong & De Felice (2018) sought to build more understanding of the

pharmacological treatment in the quest to assist in decision making, especially on the choice of

interventions. The study notes the prevalence of the condition and its impacts on the daily

functionalities of individuals. The author then highlights the symptoms, pathophysiology,

medication choices, and the intensity of the disease in the quest to identify the ideal choice of

intervention. They then compare various treatment agents, including ergot alkaloids:

Dihydroergotamine Mesylate, ergot alkaloids: ergotamine, and triptans. Also, it explores

nonspecific pharmacological treatments for acute migraines such as acetaminophen, dopamine

antagonists, corticosteroids, and opioids. The study also explored different strategies that are

used in the formulation of the interventions in the quest to ascertain the ideal ones (Ong & De

Felice, 2018).

Overall, the study notes that there is a need for care in the choice of interventions in the

quest to ascertain the effectiveness. There is a need to understand the pathophysiology in the

quest to ascertain the effectiveness of the treatments. In spite of the details in the study, the

author fails to map each type of drug with its effectiveness in the intervention. Also, the study

makes it difficult to compare and contrast the effectiveness of the interventions. There are still

some gaps in the understanding the pharmacological working of the medications and thus
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making it difficult to determine the ideal agents ideal for each type of the medication (Ong & De

Felice, 2018).

In yet another study, Thorlund et al. (2016) sought to explore the possibilities of

medications overuse in the treatment of migraines. The authors note that standard medication

may give rise to Medication Overuse Headache (MOH) in some classes as compared to others.

The study sought to show that there are certain types of medications that causes MOH. The study

was a qualitative review that involved a systematic literature review on studies that demonstrated

MOH. There were no causal comparative design studies done, the prevalence-based relative risks

were computed through medication integration of medication overuse and also studies published

on the subject.

In this study, a total of 29 studies were identified that depicted country-specific data. For

triptans against analgesics, the research on the relative risks showed lower risks in triptans. The

combined relative risk was 65% and, thus, a 35% reduction of the risk. In the cases where ergots

were compared to analgesics, ergots were found to have lower risks with a relative risk of 0.41.

In the case of triptans against ergots, the direction was haphazard, with the relative risk

increasing beyond the individual risks at 1.7. However, in the comparison between

triptans/ergots against opioids, the risk was lower at 0.35 and 0.76, respectively. The study

suggests that the use of analgesics and opioids have an elevated risk of getting MOH as

compared with other interventions. However, there was limited data to draw a valid conclusion.

Also, there were concerns about the reliability of the tests as the sample was too small. This begs

the question of whether the results can be generalized to the entire population. There is a need for

randomized trials to gather more data and map the best possible combinations that will yield the

desired outputs (Thorlund et al., 2016).

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In yet another study geared towards mapping the best possible intervention for migraines,

Young et al., 2017 sought to explore the effectiveness of opioid treatment as the primary

medication in the ED. The study identified 14 months of consecutive visits in different centers. A

total of 1222 visits were sampled in which 35.8% of the visits involved treatment with opioids.

The study noted that patients who were treated with opioids were prone to repeat visits at 1.79 as

compared to 1.3 in others. There was a 30% decreased length of stay when opioids were not used

in the intervention. The study concluded that there is a need for extra care amidst the growing

evidence of increased reports of adverse impacts of opioid medications (Young et al., 2017).

Conclusion

Overall, there are no conclusive studies geared towards assessing and recommending the

most effective opioid medications. In spite of the fact that there are numerous medications

available for the treatment of migraines, most emergency visits are treated with opioid

medications. This does not imply that it is the most effective pharmacology. Studies have

demonstrated that other pharmacology treatments such as metoclopramide and prochlorperazine

as being more effective and with fewer side effects. There is a need for a comprehensive cost-

benefit analysis of each medication to determine the best combination that will optimize the

outcomes.
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References

Connelly, M., Glynn, E. F., Hoffman, M. A., & Bickel, J. (2019). Rates and Predictors of Using

Opioids in the Emergency Department to Treat Migraine in Adolescents and Young

Adults. Pediatric Emergency Care, 1. https://doi.org/10.1097/pec.0000000000001851

Dodson, H., Bhula, J., Eriksson, S., & Nguyen, K. (2018). Migraine Treatment in the

Emergency Department: Alternatives to Opioids and their Effectiveness in Relieving

Migraines and Reducing Treatment Times. Cureus. https://doi.org/10.7759/cureus.2439

Ong, J. J., & De Felice, M. (2018). Correction to: Migraine Treatment: Current Acute

Medications and Their Potential Mechanisms of Action. Neurotherapeutics, 15(2), 525-

526. https://doi.org/10.1007/s13311-017-0599-7

Thorlund, K., Sun-Edelstein, C., Druyts, E., Kanters, S., Ebrahim, S., Bhambri, R., Ramos, E.,

Mills, E. J., Lanteri-Minet, M., & Tepper, S. (2016). Risk of medication overuse

headache across classes of treatments for acute migraine. The Journal of Headache and

Pain, 17(1). https://doi.org/10.1186/s10194-016-0696-8

Young, N., Silverman, D., Bradford, H., & Finkelstein, J. (2017). Multicenter prevalence of

opioid medication use as abortive therapy in the ED treatment of migraine

headaches. The American Journal of Emergency Medicine, 35(12), 1845-

1849. https://doi.org/10.1016/j.ajem.2017.06.015