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Few physicians are enthusiastic at the prospect of prescribing opioids for the treatment of acute or chronic pain, and for a variety of reasons, there has existed a particular bias against the use of these medications amongst clinicians who subspecialize in headache medicine.  Whatever inherent bias an individual physician harbors against the prescription of opioids may be reinforced by the very real potential for addiction associated with thisclass of drugs, “drug seeking behavior” exhibited by patients in one’s own practice and the concern that opioid therapy both may obstruct the efficacy of more conventional headache treatments and produe an unfavorable long-term outcome.

As many as 8 million Americans suffer from chronic migraine, and not surprisingly it is this segment of the migraine population that suffers the greatest migraine-related disability and accounts for a disproportionate share of the direct costs attributable to migraine diagnosis and treatment.  Clinicians who seek to treat chronic migraine must do so with an arsenal virtually bare of evidence-based therapies.  Preliminary data suggest that patients with chronic migraine may become significantly less likely to respond to therapeutic intervention if they have been experiencing daily headache for 6 months or more.

The argument in favor of considering methadone for patients with chronic migraine who have failed to respond to more conventional treatment interventions includes: 1) treatment-refractory chronic migraine is common, and any clinician whose practice is focused on headache regularly will be confronted with patients so afflicted; and 2) if these patients have failed the more commonly used prophylactic therapies, the options for management would appear to be between a) prescribing a nonopioid prophylactic therapy that is unlikely to prove efficacious b) prescribing symptomatic medication only c) referring the patient to an inpatient headache treatment center or d) prescribing a long-acting opioid (preferably methadone) for chronic headache suppression.

Intractable pain, headache or otherwise, is a devastating and life-controlling experience.  The need to effectively and aggressively control pain is a fundamental tenet of clinical care.  In the past several years, increasing adovacacy for continuous opioid therapy has become an important, if not controversial, theme in the development of treatment guidelines and teaching programs. 

Ironically, the increasing willingness of physicians to prescribe scheduled opioids for their headache and pain patients has occurred in the absence of compelling data demonstrating efficacy or long-term safety.  To the contrary, two meta-analyses on chronic noncancer pain (CNCP) and one long-term uncontrolled study on headache patients demonstrate a relatively small number of patients benefiting from the treatment. 

Recent neuroscience data on the effects of opioids on the brain raise serious concern for long-term safety and also provide the basis for the mechanism by which chronic opioid use might induce progression of headache frequency and severity.  Significant adverse effects, including influence on sexual hormonal balances, physical and psychological dependence, the development of opioid-induced hyperalgeisa, and cardiac arrhythmia and sudden death that can be seen with standard dosages of methadone, make a strong argument against widespread use of continuous opioid therapy (COT) in otherwise healthy young and middle-aged headache patients.

COT should be used in rare circumstances for chronic headache patients, and propose initial guidelines for selecting patients and monitoring treatment.  The physician should be well versed in the details of opioid prescribing, administration, and monitoring, and should be prepared to discontinue opioids when clinical justification, patient behavior, or failure to achieve therapeutic goals make discontinuance necessary.

Certain migraines are labeled as refractory, but the entity lacks a well-accepted operational definition.  A recent survey was sent to American Headache Society members to evaluate interest in a definition for refractory migraine and what were considered necessary criteria.  Review of the literature, collaborative discussions and results of the survey contributed to the proposed definition for refractory migraine.  The study also comments on considerations in formulating the criteria and any issues in making the criteria operational. 

For the proposed definition for refractory migraine and refractory chronic migraine, patients must meet the International Classification of Headache Disorders, Second Edition criteria for migraine, respectively.  Headaches need to cause significant interference with function or quality of life despite modification of triggers, lifestyle factors, and adequate trials of acute and preventive medicines with established efficacy.  The definition requires that patients fail adequate trials of preventive medicines, alone or in combination, from at least 2 of 4 drug classes including: beta-blockers, anticonvulsants, tricyclics, and calcium channel blockers.  Patients must also fail adequate trials of abortive medicines, including both a triptan and dihydroergotamine (DHE) intranasal or injectable formulation and either nonsteroidal anti-inflammatory drugs (NSAIDs) or combination analgesic, unless contraindicated.  An adequate trial is defined as a period of time during which an appropriate dose of medication is administered, typically at least two months at optimal or maximum-tolerated dose, unless terminated early due to adverse effects.

The definition also employs modifiers for the presence or absence of medication overuse, and with or without significant disability.