Australian and New Zealand Association of Neurologists
Recommendations from the Australian and New Zealand Association of Neurologists on faints, headache disorders, low back pain, migraine & narrowed carotid arteries. ANZAN aims to ensure that high standards of clinical neurology are practised in Australia and New Zealand by playing an active role in training, continuing education and encouragement of teaching and research.
Don’t use opioids for the treatment of migraine, except in rare circumstances.
Migraine is the most frequent cause of headache seen in the medical office, urgent care, or emergency department. Almost all patients should receive migraine-specific medications or non-opioid analgesics because these medications are the most effective migraine treatments. However, many patients continue to receive opioids for migraine treatment. Use of opioids increases the risk of headache and chronic migraine arising from medication overuse. The per capita cost of headache and chronic migraine arising from medication overuse is 3 times that of episodic migraine. When medical conditions such as cardiovascular disease or pregnancy preclude use of migraine-specific treatments, or when migraine-specific treatments fail, opioids are sometimes considered for rescue therapy. In these circumstances, use should be limited to 9 days per month or less to avoid medication overuse headache, and doctors should continue to focus on preventive and behavioural aspects of migraine care. In addition, long-term follow-up is needed to prevent treatment complications.
- Bigal ME, Serrano D, Buse D, et al . Acute migraine medications and evolution from episodic to chronic migraine: a longitudinal population-based study. Headache 2008;48(8):1157-68.
- Evers S, Afra J, Frese A, et al. European Federation of Neurological Societies. EFNS guideline on the drug treatment of migraine – revised report of an EFNS task force. Eur J Neurol [Online] 2009;16(9):968-81.
- Tepper SJ. Opioids should not be used in migraine. Headache 2012;52; S1:30-4.
The ANZAN Council considered 12 clinical practices in neurology which may be overused, inappropriate or of limited effectiveness in a given clinical context. After choosing the top 5 items to prioritise, these were passed on to the appropriate subspecialty committees within ANZAN for comment and additional suggestions. The final list of the top 5 items chosen was compiled following a review of the evidence and the formulation of suitable recommendations and endorsed by the Council on 7th January 2016.
- 1 Don’t perform imaging of the carotid arteries for simple faints.
- 2 Don’t perform imaging of the brain for non-acute primary headache disorders.
- 3 Don’t perform epidural steroid injections to treat patients with low back pain who do not have radicular symptoms in the legs originating from the nerve roots.
- 4 Don’t use opioids for the treatment of migraine, except in rare circumstances.
- 5 Don’t routinely recommend surgery for a narrowed carotid artery (>50% stenosis) that has not caused symptoms.