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.