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Three Part Question

In [children and adolescents with known migraine] is the [use of opioids appropriate] to [provide pain relief]?

Clinical Scenario

A 13 year old boy presents to the Emergency Department with a three hour history of a severe throbbing headache. He has taken nasal sumatriptan two hours previously and has obtianed little relief, he is currently extremely uncomfortable. He is a known migraine sufferer and has had two other episodes in the last month. After history and clinical examination, a diagnosis of migraine is made. You wonder if the use of an opioid would be appropriate to resolve his symptoms.

Search Strategy

Medline 1950-July 2010 using Ovid interface
EMBASE 1980-July2010 using Ovid interface
Cochrane Database of Systematic Reviews (July 2010)

Medline
[(Exp migraine disorders OR exp Headache OR exp Primary Headache Disorders OR exp Headache Disorders) AND (exp Opioid Analgesics OR Codeine) AND (LIMIT to English language AND Humans) AND (LMIT to “All Child (0-18 years)”)]
EMBASE
[(Exp migraine aura OR exp migraine without aura OR exp migraine with aura OR exp migraine OR exp headache OR exp primary headache) AND (exp Opiate OR exp codeine) AND (LIMIT to (Human and English Language)) AND (LIMIT to (child OR preschool child <1 to 6 years> OR school child <7 to 12 years> OR adolescent <13 to 17 years>)
Cochrane Database of Systematic Reviews (July 2010)
Search’migraine’ (ti,ab,kw)

Search Outcome

56 papers found in Medline, none were relevant
3 papers found in EMBASE, 1 was relevant
98 papers found in Cochrane, 1 was relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
H. B. Siden et al 2005 Vancouver	3 paediatric patients (one infant and two adolescents), all had been given opioid therapy. One patient (16 year old female) had used it for chronic headache with migraine, and was admitted to hospital due to opiate dependence (diagnosed with intracranial primitive neuroectodermal tumour 5 years previously, she had complex medical problems).	Parallel case paper	pain relief using butorphanol nasal spray every 2-4h + paracetamol with codeine every 4h	momentary relief but wore off quickly	Only one patient with symptomatic migraine. Weakly related to clinical question; migraine was not a primary headache disorder and due to underlying secondary aetiology, case was not an acute situation and was more related to chronic pain.
			side effects	addiction; one 2.5ml bottle of butorphanol lasted two days; equivalent to 150g oral morphine per day.
			rapid withdrawal	Reduction of opiate dose by 50% each day for four days
L. Billinghurst et al 2009; awaiting review Canada	currently under construction	Intervention Protocol for a review	Objective;To describe and assess the evidence from controlled trials on the efficacy and tolerability of pharmacological interventions by any route of administration versus placebo or other drug treatments for acute attacks of migraine in children	n/a	Results are currently unavailable, but eventually may be relevant to clinical question.

Comment(s)

It is generally not recommended to use opioids in children for pain relief due to their addictive properties. However there is no high quality evidence for its use for migraines in children or adolescents at all, and research needs to be carried out to assess its possible benefits in acute scenarios for this population.

Clinical Bottom Line

The use of opioids is not appropriate for treatment of migraines in children and adolescents due to their addictive properties and insufficient evidence.

References

1. H. B. Siden, K. Collin Three patients and their drugs: A parallel case paper on paediatric opiate use and withdrawal Paediatrics & Child Health 2005; 10 (3): 163-168
2. L. Billinghurst, L. Richer, KF Russell et al Drugs for treating acute migraine headaches in children and adolescents (protocol) The Cochrane Collaboration 2009; Issue 1:1-9