Opioids for Migraine: What a 12,612-Person International Survey Found
A survey of 12,612 people with migraine in six countries found nearly 1 in 4 used opioids for headache. Users reported more disability and four times the ER and hospital visits, though cause is unclear.
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Why Opioids Are Not Recommended for Migraine
Opioids are not a recommended treatment for migraine. Headache guidelines, including the American Headache Society's consensus statement, advise against using them for migraine attacks except in limited situations, such as when other options are contraindicated or have failed. Even so, many people with migraine still use them, often from an emergency department visit, an old prescription, or a combination pill containing codeine.
There are three main reasons headache specialists steer people away from opioids:
- They are less effective for migraine than migraine-specific treatments. Opioids dull pain in general, but they don't target the processes that drive a migraine attack.
- They can make migraine more frequent over time. In a large US population study, opioid use was linked to a higher risk of progressing from episodic to chronic migraine, with the risk rising at around 8 or more days of use per month.
- They can cause medication overuse headache. Using opioids on 10 or more days a month for more than 3 months meets the diagnostic threshold for medication overuse headache. Our medication overuse headache checker walks through the criteria.
A new analysis in Headache, the journal of the American Headache Society, looked at how often people with migraine use opioids across six countries and how opioid users compare with nonusers on disability, self-reported cognitive problems, and healthcare use.
How the Study Worked
The data came from the Chronic Migraine Epidemiology and Outcomes-International (CaMEO-I) Study, a web-based survey run in six countries from 2021 to 2022. Respondents were classified as having migraine using a validated questionnaire based on the International Classification of Headache Disorders, 3rd edition. This paper is a post hoc analysis, meaning the opioid comparison was done after the survey was collected rather than being the study's original main question.
The analysis included people with migraine who used any prescription or over-the-counter medication to treat their headaches. Anyone who had used opioids for headache in the previous 30 days, or kept opioids on hand for that purpose, was counted as an opioid user.
To compare disability fairly, the researchers adjusted for age, sex at birth, whether the person was seeing a headache specialist, education, employment, and how well their acute treatment was working.
How Common Opioid Use Was
Nearly 1 in 4 respondents (23.5%, or 2,965 people) had used opioids for headache in the past month or kept them on hand. Rates differed sharply by country.
A sixfold gap between countries suggests that opioid use for migraine reflects local prescribing habits, drug availability, and how combination products are sold, not only how severe people's migraine is.
"Opioid user" here includes people who kept opioids on hand for headache without necessarily taking them. It also covers any opioid, from low-dose codeine combinations to stronger prescription drugs. The study did not separate results by opioid type or by how many days a month people used them.
Disability and Treatment Optimization
Opioid users were more likely than nonusers to report moderate to severe disability. The gap held at every level of acute treatment optimization, so it was not only explained by opioid users having less effective treatment overall.
Moderate to Severe Disability by Treatment Optimization
Share of respondents with moderate to severe disability on the MIDAS, grouped by how well their acute treatment worked (mTOQ).
| Acute treatment optimization | Opioid users | Nonusers | Difference |
|---|---|---|---|
| Very poor | 64.7% (123 of 190) | 49.7% (373 of 750) | 15.0 points higher |
| Poor | 62.6% (1,110 of 1,772) | 46.5% (2,208 of 4,747) | 16.1 points higher |
| Moderate | 51.0% (338 of 663) | 35.6% (824 of 2,314) | 15.4 points higher |
| Maximum | 38.8% (132 of 340) | 19.9% (366 of 1,836) | 18.9 points higher |
Better acute treatment went with less disability in both groups, and poorer optimization was a significant predictor of moderate to severe disability in the adjusted model. Even among people whose treatment was rated as working at the maximum level, opioid users were about twice as likely to report moderate to severe disability (38.8% vs 19.9%).
Opioid users were also more likely to have poorly optimized treatment to begin with. About 66% of opioid users fell into the poor or very poor categories, compared with about 57% of nonusers. In the adjusted analysis, opioid use was linked to greater disability in every one of the six countries.
Thinking, Memory, and Focus
Many people with migraine describe brain fog, trouble finding words, or difficulty concentrating, both during attacks and between them. The survey measured this with the MCIQ, where a higher score means more reported cognitive difficulty.
The difference was statistically significant. The MCIQ is a questionnaire about how people perceive their own thinking, not a test of memory or attention. The finding also can't separate the effect of opioids from the effect of having more frequent or more severe migraine attacks, which on their own are linked to more cognitive complaints.
Doctor, ER, and Hospital Visits
Over the previous 6 months, opioid users were far more likely to have needed medical care for headache.
The relationship likely runs in both directions. People with harder-to-control migraine end up in the emergency department more often, and emergency departments are one of the places opioids still get prescribed for migraine. The survey can't tell which came first for any given person.
What This Study Can't Tell Us
The authors state directly that causality can't be determined from this design. Several features of the study matter when reading the results.
- It was cross-sectional. Everything was measured at one point in time, so the study can't show whether opioids led to more disability or whether more disabled people were more likely to be given opioids.
- It relied on self-report. Migraine status, medication use, disability, cognitive symptoms, and healthcare visits all came from what respondents reported in an online survey.
- Headache frequency was not one of the adjustment factors. The disability model adjusted for treatment optimization and demographics, but not for monthly headache days, a major driver of both disability and opioid prescribing.
- Opioid use was broadly defined. Keeping opioids on hand counted, and there was no breakdown by drug, dose, or days of use per month.
- It was a post hoc analysis. The question was examined after the survey was collected.
- Industry involvement. Two of the authors are employees of AbbVie, which makes several migraine treatments.
Even with these limits, the findings line up with earlier longitudinal research showing that opioid use is linked to migraine becoming more frequent over time. The new data add a wider international picture and the observation that opioid users report more disability even when their acute treatment seems to be working well.
Better Options to Ask About
The authors conclude that the results support a need for better treatment optimization. If you use opioids for migraine attacks, or keep them around just in case, that is a useful prompt for a conversation with your clinician. Stopping or changing any medication should be done with medical guidance, especially if you have been using opioids regularly.
Migraine-Specific Acute Treatments
Options recommended by headache guidelines for treating migraine attacks. Which one fits depends on your health history, other medications, and cost.
| Drug class | Examples | Notes |
|---|---|---|
| Triptans | sumatriptan (Imitrex), rizatriptan (Maxalt), zolmitriptan (Zomig) | Long-standing first-line option; available as tablets, nasal sprays, and injections. Not suitable for people with certain cardiovascular conditions. |
| Gepants | rimegepant (Nurtec ODT), ubrogepant (Ubrelvy), zavegepant (Zavzpret) | Block the CGRP receptor; an option when triptans don't work or aren't safe. Current evidence suggests they are unlikely to cause medication overuse headache. |
| Ditan | lasmiditan (Reyvow) | Does not constrict blood vessels; can cause dizziness and drowsiness, so no driving for 8 hours after a dose. |
| NSAIDs and combination analgesics | ibuprofen (Advil, Motrin), naproxen (Aleve), acetaminophen, aspirin, and caffeine (Excedrin) | Effective for many mild to moderate attacks; can be combined with a triptan. |
A recent 25-trial analysis compared over-the-counter painkillers with gepants and lasmiditan.
If attacks are frequent, preventive treatment can reduce how often acute medication is needed at all. The new AAN and AHS prevention guideline covers the options, which include CGRP monoclonal antibodies such as erenumab (Aimovig), fremanezumab (Ajovy), galcanezumab (Emgality), and eptinezumab (Vyepti), the daily gepant atogepant (Qulipta), onabotulinumtoxinA (Botox) for chronic migraine, and older oral drugs like topiramate (Topamax) and propranolol (Inderal LA).
- How many days a month am I using any acute medication, and is that putting me at risk of medication overuse headache?
- Have I tried a triptan, gepant, or ditan, and at the right dose and timing?
- Would a preventive treatment make sense for how often my attacks happen?
- If I have been using opioids regularly, what is a safe plan for reducing them?
Our free printable appointment summary can help you bring your attack and medication numbers to the visit.
Key Takeaways
The study can't show that opioids caused the extra disability, and some of the gap probably reflects people with more severe migraine being prescribed opioids in the first place. Regular opioid use for migraine is a sign that treatment could be improved, and migraine-specific acute and preventive options are worth discussing with a clinician.
This article is for educational purposes only and is not a substitute for professional medical advice, diagnosis, or treatment. Do not stop or change any medication, including opioids, without talking to a qualified healthcare provider. Stopping opioids suddenly after regular use can cause withdrawal symptoms.
References
- Leroux E, Buse DC, Lanteri-Minet M, et al. Opioid use, disability, and patient-reported cognitive impairment in migraine: Multi-country results from the Chronic Migraine Epidemiology and Outcomes-International Study. Headache. Published online October 2026. doi:10.1111/head.70241.
- Ailani J, Burch RC, Robbins MS. The American Headache Society Consensus Statement: Update on integrating new migraine treatments into clinical practice. Headache. 2021;61(7):1021-1039. doi:10.1111/head.14153.
- Bigal ME, Serrano D, Buse D, et al. Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache. 2008;48(8):1157-1168. doi:10.1111/j.1526-4610.2008.01217.x.
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211. doi:10.1177/0333102417738202.
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