Choosing Wisely:

Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

Rationale and Comments: These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.
Sponsoring Organizations:
  • American Headache Society
  • Sources:
  • Expert consensus
  • Disciplines:
  • Neurologic
  • References: • Bigal ME, Lipton RB. Excessive opioid use and the development of chronic migraine. Pain. 2009 Apr;142(3):179-82.
    • Bigal ME, Serrano D, Buse D, Scher AI, Stewart WF, Lipton RB. Migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48:1157-68.
    • Scher AI, Stewart WF, Ricci JA, Lipton RB. Factors associated with the onset and remission of chronic daily headache in a population-based study. Pain. 2003;106(1-2):81-9.
    • Katsarava Z, Schneeweiss S, Kurth T, Kroener U, Fritsche G, Eikermann A, Diener HC, Limmroth V. Incidence and predictors for chronicity of headache in patients with episodic migraine. Neurology. 2004 Mar;62(5):788-90.

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