Medication stewardship here means judging every headache drug by one measure: fewer headache days. We count how many days a month you treat, not only the dose. A medication doing real work stays. One quietly driving the frequency up is named plainly.
Most people want one question answered. Does coming here mean their medication gets 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
People often hear stewardship as a polite word for refusal. That is not what it means in this clinic. It means matching the medication to the mechanism. It means watching the frequency, not only the dose. And it means being honest when a drug that helps today is the reason for 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. That is because no preventive treatment will outrun it.
How many days a month can you take headache medication?
Here is the single most useful idea in headache medicine. 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 set thresholds for each class. Past these, episodic headache is most likely to transform into chronic headache. They are 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: keep acute treatment to two days a week or fewer.1 Most people are surprised by how low that is. They are also surprised by how easily a bad month crosses it. The full diagnostic criteria are in medication-overuse headache. It is the single most important article on this site.
Why are butalbital and opioids a poor choice for headaches?
Butalbital is a barbiturate. It is 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 gives a partial response. The headache returns, the dose is repeated, and the pattern sets in.2 Less effective treatment leads to redosing, which leads to chronification (the headache becoming chronic).
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. It is worth reading carefully. It is a statement about what should be tried first. It is not a declaration that these drugs have no place in medicine.
When are opioids still the right treatment?
This practice treats several conditions in which opioids are legitimate and sometimes necessary. In these, withholding them would be a failure of care, not 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. But the same reasoning does not apply to migraine. In migraine, opioids treat the pain poorly and worsen the nausea. They interfere with the drugs that do work. And they cross into overuse at a low threshold.
How do you stop overusing headache medication?
Why do people fail to unwind this alone? Because stopping makes the headache worse before it makes it better. 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 starts at the same time, not afterward. So something is holding the floor as the acute medication comes out.1
Nobody is asked to stop a medication and simply endure the result. If that is what you were 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 figures below from its own population. That 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. They are 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. We quote them because the mechanism behind them is what matters. Treating the pain source directly is what makes a taper possible. So the reduction is a result, not a condition imposed at the start.
Frequently asked questions
Are you going to take away the medication that works for me?
No. The question here is how many days a month you are treating, not whether you are treating. Has the frequency crossed a threshold that is driving your headaches? Then we discuss it and make a plan 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. The guidelines are explicit about that.3 For migraine specifically, they work poorly and interfere with the drugs that do work. They also cross into overuse at eight days a month.1 The treatments we use 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. 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 set up.
What if I am on opioids for a different condition as well?
That is common. We handle it as its own question, not folded into the headache plan. Several conditions treated in this group truly 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. It is worth saying plainly, because it stops people from 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.
What is the best medication for headaches?
The best medication is the one that lowers the number of headache days you have each month. It is matched to what is driving your headaches. How often you take it matters as much as the drug itself. NSAIDs are the most forgiving and butalbital the least. For a severe attack, this clinic uses intravenous therapy and nerve blocks. These do not feed the overuse cycle.
Is butalbital an opioid?
No. Butalbital is a barbiturate. It is usually combined with acetaminophen or aspirin and caffeine. It is still widely prescribed for headache in the United States. It crosses into medication overuse faster than any other class, at about five days a month. Like opioids, any use of it raises the likelihood of episodic headache turning into chronic headache.
Do doctors still prescribe butalbital?
Yes, it is still widely prescribed in the United States. The American Headache Society’s Choosing Wisely list says it should not be a first-line treatment for recurrent headache. That is a statement about what should be tried first, not a ban. If you have taken it for years, we review it with you. It should never be stopped abruptly on your own.
Sources
- Tepper SJ. Medication-overuse headache. Continuum (Minneap Minn). 2012;18(4):807-822. doi:10.1212/01.CON.0000418644.32032.7b
- 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
- 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
Fewer daily pills is a goal of our headache treatment in St. Louis, not a side effect. Procedures such as nerve blocks are often what makes cutting back possible.