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Feature Article

Codeine and headache. ‘Doctor, I just need a script for my headaches’

Shuli Cheng, Elspeth Hutton
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© deagreez/stock.adobe.com   model used for illustrative purposes only
© deagreez/stock.adobe.com model used for illustrative purposes only

Abstract

Harms associated with codeine-based treatments for headache include medication overuse headache and accidental overdose. Suggested management of patients with headache and codeine dependence includes education about harms of codeine, codeine withdrawal with bridging therapy if required, preventive medications and acute treatment for the primary headache disorder, and advice on lifestyle measures.

Key Points

  • Opioid use for episodic migraine is one of the greatest risks for transformation to chronic migraine.
  • Lifestyle measures are integral to chronic headache management.
  • Codeine is usually withdrawn gradually, with use of a bridging strategy if required.
  • Starting a preventive medication is usually recommended at the same time as withdrawing codeine.

Many patients rely on over-the-counter medications to manage headache, without seeking medical advice. A study of patients presenting to their community pharmacy for headache management in Ireland found that codeine-based products were the preferred analgesic medications (43%), and 53% had never consulted their GP for headache. Thirty to fifty percent had episodic migraine and 11% had chronic daily headache in this surveyed cohort.1 

With the upscheduling of codeine in Australia, more headache sufferers will present to their GPs to request a codeine prescription or alternative treatment for their primary headache disorder. This is an opportunity to educate and change their management strategies to reduce harm and increase efficacy. This article discusses the management of patients who use codeine-based medications to treat headache. 

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What harms are associated with codeine use for headache?

Chronic migraine affects 1 to 2% of the population, with an annual rate of transformation from episodic migraine of 2.5%.2 Opioid use for episodic migraine is one of the greatest risks for transformation to the chronic form (44% increased risk).2,3

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Medication overuse headache is a significant problem in management of patients with chronic headache. The main drivers of its development are the use of opioid analgesics, triptans or ergots on more than 10 days per month. People with comorbid depression, anxiety and poor sleep are more susceptible to developing medication overuse, and these issues should always be explored and appropriately managed in patients with headache.4 About 30% of patients will have a significant reduction in headache severity and frequency if the only change in their management is cessation of codeine use.5

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© deagreez/stock.adobe.com   model used for illustrative purposes only
© deagreez/stock.adobe.com model used for illustrative purposes only
Dr Cheng is a Neurologist at Alfred Health, Melbourne. Dr Hutton is a Neurologist at Alfred Health, Melbourne; and Research Fellow in the Neurosciences Department, Monash University, Melbourne, Vic.