The diagnosis and treatment of chronic migraine: the case for daily scheduled opioid treatment in chronic headache

As a clinical neurologist with special interest in headache, I read the recent article by Weatherall in your journal with interest [Weatherall, 2015]. However, I was astounded by the lack of any reference in the article to the therapeutic role of opiates in the management of headaches in those with acute or chronic migraine. This omission seems to have been based on the author’s emphasis on medication overuse headache (MOH) and his belief on a causal role played by opiates in the genesis of chronic daily headache (CDH) (he used those two terms interchangeably).

Apart from the ongoing debate on the causative role of opiates and other analgesics in the development of MOH [Cady et al. 2011], the role of daily scheduled opioids in securing a headache-free existence to a significant portion of those suffering from disabling headaches is well documented in the literature [Levin, 2014; Robbins, 2014; Saper et al. 2004; Spierings 2003; Saper et al. 2010; Ziegler, 1994]. Similarly, opioids continue to be used as the last resort in treating pediatric and adult populations with headaches who visit emergency rooms across the United States and in Canada [Burch et al. 2015; Colman et al. 2004; Eapen et al. 2014]. In the words of Thomas Sydenham: ‘I cannot but break out in praise of the great God, the giver of all good things, who both granted to the human race, as a comfort in their afflictions, no medicine of the value of opium…. So necessary an instrument is opium in the hands of a skillful man that medicine would be a cripple without it’ [quoted in Ziegler, 1994].