The harms associated with long-term codeine and opioid use extend beyond the risk of medication overuse headache and transformation to chronic migraine. They include:6
- accidental overdose and death, particularly with polypharmacy (especially with concomitant benzodiazepines)
- worsening overall pain, development of body pain and opioid-induced hyperalgesia
- depression and anxiety
- opioid-induced impairment of the hypothalamic-pituitary-adrenal axis leading to decreased sexual function, disruption of the menstrual cycle, osteoporosis, fatigue and weight gain.
Management of a patient with headache and codeine dependence
Suggested steps in managing a patient with headache and codeine dependence are summarised in Box 1.
Educate the patient about the harms of codeine
After exclusion of primary headache disorders that require prompt specialist referral and red flags, the first step in managing patients with headache and codeine dependence is to reassure them that there are many more effective and better tolerated ways of managing their chronic headache that do not carry the same risks as codeine. It is important that patients do not feel persecuted or blamed for their codeine dependence. It is also important that they understand codeine is not the best long-term option and is probably making their headaches worse. A suggested patient handout on codeine and headaches is available here.
Many patients believe that codeine works, as their headache settles slightly and then flares when the dose wears off, prompting another dose to be taken. Explaining that this is not actually a sign of how well the medication is working but rather a sign of withdrawal headache is important in engaging patients with the withdrawal process.
It is also helpful to outline to patients the timeline for codeine withdrawal. Codeine withdrawal will ultimately help their headache control, but they need to get through the withdrawal period first, which can last about three weeks. During this time they may have transient worsening of headache, as well as other symptoms such as anxiety, cold sweats, diarrhoea and nausea, depending on the degree of their dependence. There are strategies to minimise these symptoms for them.
Recommend patient self-care for headache management
In all patients with frequent or chronic headache, lifestyle measures to manage headache should be reinforced. These include:
- adequate amounts of good-quality sleep, with regular sleeping hours. For patients with problems initiating sleep, a trial can be considered of melatonin 2 mg one hour before bedtime for four to six weeks to reset the sleep cycle, in conjunction with good sleep hygiene. Useful advice on sleep hygiene is available at the Better Health website (www.betterhealth.vic.gov.au/health/conditionsandtreatments/sleep-hygiene).
- regular meals, low in simple sugars and refined carbohydrates. Patients should not skip meals.
- drinking plenty of water to stay well hydrated; 1.5 to 2 litres daily is suitable for most people except those who require fluid restriction for medical reasons.
- regular exercise – walking, swimming and cycling are all good options for people with headaches. Running, aerobics and other activities that involve jumping or thumping can aggravate headache and are probably best avoided.
- limiting caffeinated drinks to a maximum of two cups daily. Patients with sleep problems should avoid caffeine after 3 pm.
- avoiding known headache triggers. Common food triggers for migraine include chocolate, strong cheeses, flavour enhancers such as monosodium glutamate (MSG), citrus, preserved meats and alcohol. Food triggers are often specific to the individual, but it is recommended that patients explore the common triggers to assess their contribution to migraines. If a clear association is found then it is sensible to avoid that food. However, in the absence of obvious food triggers, a restrictive diet is not helpful.
- good workplace ergonomics, particularly for computer users. Take regular ‘mini-breaks’ every 45 minutes to stand, stretch and rest the eyes for a few minutes.
- regular use of a relaxation technique, which can help manage stress. This might include meditation, mindfulness, yoga, progressive muscle relaxation, breathing techniques or guided relaxation using a phone app.