Literature Review

Opioids Are Overprescribed for Migraine

An investigation into racial disparities in migraine treatment found no evidence of such but did find that opioids are overused, migraine-specific drugs are underused, and migrainerurs may be undertreated with preventive medications.


Opiates are overused, and acute analgesics with high-quality evidence may be underused, for the treatment of migraine, according to research published online ahead of print June 26 in Cephalalgia. In addition, migraine may be undertreated with preventive medications. These prescribing patterns do not significantly differ by patients’ race, however.

Larry Charleston IV, MD

“People were prescribed opioids as much as they were prescribed medications that are much better for migraines,” said lead author Larry Charleston IV, MD, Assistant Professor of Neurology at the University of Michigan Medical School in Ann Arbor. Opiate-related mortality is rapidly increasing in the United States. Evidence suggests that opiates are less effective than nonopiate alternatives and should be used rarely, if at all, the authors noted.

Analyzing Nationally Representative Data

In the US, racial disparities in migraine burden have been reported. Migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life, compared with migraine in non-Hispanic whites. Lower-quality medication treatment for migraine may explain this difference, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist.

Dr. Charleston and James F. Burke, MD, Associate Professor of Neurology at the University of Michigan Medical School, hypothesized that racial differences in the use of high-quality abortive, prophylactic medications would exist in ambulatory care settings, and that the quality of medical treatment for migraine disorders would be suboptimal in minority populations. To test these hypotheses, they analyzed all headache visits for patients over age 18 in the National Ambulatory Medical Care Survey (NAMCS) from 2006 to 2013.

The investigators defined quality of migraine care by using the American Academy of Neurology Headache Quality Measure Set. Researchers then assigned patients to one of three race or ethnicity categories—non-Hispanic white, African American, and Hispanic. Patients who reported other races or ethnicities were excluded.

The researchers assigned patients to one of four abortive agent categories—no abortive agent prescribed, all high-quality abortive agents (ie, triptans or dihydroergotamine), some low-quality abortive agents, or any opiate agent. In addition, the investigators assigned patients to one of four prophylactic agent categories—no prophylactic agent, all high-quality prophylaxis, some low-quality prophylaxis, or all low-quality prophylaxis. Finally, researchers made racial comparisons using descriptive statistics after applying NAMCS survey weights.

Prophylactic Agents Are Likely Underused

A total of 2,860 visits were included in the study, representing approximately 50 million migraine visits in the US from 2006 to 2013; 76% of patients were non-Hispanic white, 10% were African American, and 10% were Hispanic. Hispanic patients were more likely to be seen in a given practice for the first time, compared with non-Hispanic whites or African Americans. Researchers also observed a trend toward less private insurance and more Medicaid among African American and Hispanic patients, compared with non-Hispanic white patients.

Although overall migraine prescribing patterns were suboptimal, researchers did not find any major differences by race. “It is possible, though, that more modest racial differences in abortive prescribing exist, but that we lacked statistical power to identify those differences,” said Drs. Charleston and Burke.

In all, 41.3% of African Americans, 40.8% of non-Hispanic whites, and 41.2% of Hispanic patients received no prophylactic treatment. A total of 18.8% of African Americans, 11.9% of non-Hispanic whites, and 6.9% of Hispanic patients received exclusively Level A prophylaxis.

Forty-seven percent of African Americans, 38.2% of non-Hispanic whites, and 36.3% of Hispanic patients received no abortive treatments. In all, 15.3% of African Americans, 19.4% of non-Hispanic whites, and 17.7% of Hispanic patients received exclusively Level A abortive agents. About 15.2% of patients had a prescription for opiates, but no racial differences were observed.

In addition, African Americans were 4% less likely to receive all high-quality abortive agents, and Hispanic patients were 5% less likely to receive all high-quality prophylactic agents, compared with non-Hispanic whites. Neither of these differences was statistically significant, said the researchers.

“Understanding what drives these prescribing patterns and improving overall migraine prescribing should be a central concern for headache care practitioners and quality-improvement initiatives, and a target of future interventions,” said Drs. Charleston and Burke.

One limitation of this study was that researchers had no details on headache severity or duration. Another limitation was that the researchers did not control for socioeconomic status.

—Erica Tricarico

Suggested Reading

Charleston IV L, Burke JF. Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care? Cephalalgia. 2017 Jun 26 [Epub ahead of print].

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