Medication stewardship

The question most people actually want answered is whether coming here means having their medication taken away. It does not. The goal is fewer headache days. Medication is judged against that goal — not against a target of taking nothing.

What stewardship means here

Stewardship is often heard as a polite word for refusal. That is not what it means in this clinic. It means matching the medication to the mechanism, watching the frequency rather than only the dose, and being honest when a drug that is helping today is the reason there will be a headache tomorrow.

It is the management of difficult situations and the reduction of harm, not a policy of abstinence. Where a medication is doing real work, it stays. Where it is quietly driving the frequency up, that has to be said plainly, because no preventive treatment will outrun it.

The numbers that actually matter are days, not doses

The single most useful idea in headache medicine is that the number of days per month you treat matters more than how much you take on any one day. Different drug classes cross that line at very different points.

Data from the American Migraine Prevalence and Prevention study put the thresholds at which episodic headache is most likely to transform into chronic headache at roughly:¹

• Butalbital — 5 days a month. The lowest threshold of any class.
• Opioids — 8 days a month.
• Triptans or combination analgesics — 10 days a month.
• NSAIDs — 10 to 15 days a month. The most forgiving of the group, and at low frequency NSAIDs may even be protective.

The working rule that falls out of this is to keep acute treatment to two days a week or fewer.¹ Most people are surprised by how low that is, and by how easily a bad month crosses it. The full diagnostic criteria are set out in medication-overuse headache, which is the single most important article on this site.

Why butalbital and opioids sit at the bottom of the list

Butalbital is a barbiturate, usually combined with acetaminophen or aspirin and caffeine. It is still widely prescribed for headache in the United States, and it crosses into medication overuse faster than anything else — five days a month.¹ Use of any barbiturate or opioid increases the likelihood of episodic headache transforming into chronic headache.¹

The mechanism is not mysterious. A drug that is not specific for the headache produces a partial response, the headache returns, the dose is repeated, and the pattern establishes itself.² Less effective treatment leads to redosing, which leads to chronification.

The American Headache Society’s Choosing Wisely list puts it directly: do not prescribe opioid- or butalbital-containing medications as a first-line treatment for recurrent headache disorders.³ The word first-line is doing real work in that sentence, and it is worth reading carefully. It is a statement about what should be tried first, not a declaration that these drugs have no place in medicine.

Where opioids remain appropriate

This practice treats several conditions in which opioids are legitimate and sometimes necessary, and withholding them would be a failure of care rather than good stewardship:

• Head and neck cancer pain, including pain from the treatment as well as the disease.
• Destructive facet disease in the cervical spine, where the joint itself is being lost.
• Failed neck surgery, particularly after fusion, where the anatomy limits what any interventional approach can reach.

These are not loopholes. They are different clinical problems from primary headache, and they are judged on their own terms. What does not follow is that the same reasoning applies to migraine, where opioids treat the pain poorly, worsen the nausea, interfere with the drugs that do work, and cross into overuse at a low threshold.

If you are already taking too much

The reason people fail to unwind this alone is that stopping makes the headache worse before it makes it better, and that worsening is easily read as proof the medication was necessary. It is not. It is withdrawal, and the window is usually days to a couple of weeks.

What makes that period survivable is covering it with treatment that does not feed the cycle. Intravenous therapy can break an acute headache during withdrawal without adding to the overuse. A nerve block can do the same. Preventive treatment is started at the same time rather than afterward, so there is something holding the floor as the acute medication comes out.¹

Nobody is asked to stop a medication and simply endure the consequence. If that is what has been offered before, it is a reasonable explanation for why it did not work.

What the affiliated pain practice’s own figures show

Headache Express sits within a group of practices under the same physician. The affiliated interventional pain practice reports the following from its own population — which is a chronic pain population, not a headache population, so these numbers describe that group and not headache patients specifically:

• On arrival, the average new patient has been in pain more than two and a half years and is taking more than 90 morphine milligram equivalents a day.
• Under active interventional treatment, 21% are completely weaned off opioid pain medication within 90 days, and 34% within one year. Of those who cannot be fully weaned, the large majority are brought below 30 MME a day.
• Across the established population, fewer than 1% remain above 90 MME a day.

These are practice-reported figures from our own population, not trial outcomes, and individual results vary. They are quoted here because the mechanism behind them is the relevant part: treating the pain source directly is what makes a taper possible, so the reduction is a result rather than a condition imposed at the start.

Common questions

Are you going to take away the medication that works for me?

No. The question asked here is how many days a month you are treating, not whether you are treating. If the frequency has crossed a threshold that is driving your headaches, that gets discussed and a plan is made to cover the transition — see medication-overuse headache. Contact us if you want to know where you stand before booking.

Do you prescribe opioids for migraine?

Opioids are not a first-line treatment for recurrent headache, and the guidelines are explicit about that.³ For migraine specifically they work poorly, interfere with the drugs that do work, and cross into overuse at eight days a month.¹ The treatments used here for a severe attack are intravenous therapy and nerve blocks.

I have been on butalbital for years. Is that a problem?

It is worth reviewing. Butalbital has the lowest overuse threshold of any class at about five days a month, and any barbiturate use raises the likelihood of episodic headache becoming chronic.¹ That does not mean stopping abruptly on your own — see medication-overuse headache for how a wean is actually structured.

What if I am on opioids for a different condition as well?

That is common and it is handled as its own question rather than folded into the headache plan. Several conditions treated in this group genuinely warrant opioid therapy, including head and neck cancer pain. The aim is minimizing harm, not reaching zero.

Will I be judged for how much I am taking?

No, and it is worth saying plainly because it stops people seeking help. Most people arriving on high-frequency acute medication got there by following instructions and treating their pain. The frequency is a clinical fact to work with — see chronic or episodic migraine for why counting honestly matters more than it seems.

Sources

1. Tepper SJ. Medication-overuse headache. Continuum (Minneap Minn). 2012;18(4):807-822. doi:10.1212/01.CON.0000418644.32032.7b
2. Tepper SJ, Tepper DE. Breaking the cycle of medication overuse headache. Cleve Clin J Med. 2010;77(4):236-242. doi:10.3949/ccjm.77a.09147
3. Loder E, Weizenbaum E, Frishberg B, Silberstein S. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53(10):1651-1659. doi:10.1111/head.12233