Is hydromorphone (Dilaudid) effective for treating headaches?

Hydromorphone for Headache Treatment

Hydromorphone (Dilaudid) is not recommended as first-line therapy for headaches and should be reserved only for cases where other medications cannot be used, when sedation effects are not a concern, or when the risk for abuse has been addressed. 1, 2

Evidence Against Hydromorphone for Headaches

• Hydromorphone is substantially less effective than other treatments for acute migraine. In a randomized study, IV prochlorperazine plus diphenhydramine achieved sustained headache relief in 60% of patients compared to only 31% with hydromorphone (number needed to treat = 4) 3

• Opioids, including hydromorphone, should be reserved as last-line agents for headache treatment due to:

  • Risk of medication-overuse headache with frequent use 2
  • Potential for dependency and abuse 4
  • Limited evidence supporting efficacy specifically for headache treatment 1

• Hydromorphone has potent euphoric effects that may contribute to its abuse liability, making it particularly concerning for headache treatment which often requires repeated dosing 4

Recommended First-Line Treatments for Headaches

• NSAIDs are recommended as first-line treatment for mild to moderate migraine attacks due to their demonstrated efficacy and favorable tolerability 2

  • Specific NSAIDs with strong evidence include aspirin, ibuprofen, naproxen sodium, and combination medications containing acetaminophen, aspirin, and caffeine 2

• Triptans (serotonin1B/1D agonists) are recommended as first-line therapy for moderate to severe migraine attacks 2

  • Oral triptans with good evidence include naratriptan, rizatriptan, sumatriptan, and zolmitriptan 2
  • Subcutaneous and intranasal sumatriptan are particularly useful for patients with nausea and vomiting 2

Second-Line and Rescue Treatments

• Antiemetics, particularly intravenous metoclopramide (10 mg IV), may be appropriate as monotherapy for acute attacks, especially when nausea and vomiting are present 2, 5

• Prochlorperazine (10 mg IV) effectively relieves headache pain and has been shown to be comparable to metoclopramide in efficacy 2

• Intranasal dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks 2

When Opioids Might Be Considered

• Opioids should only be considered when:

  • Other evidence-based treatments have failed or are contraindicated 1
  • Sedation effects are not a concern 1
  • The risk for abuse has been addressed 1
  • The patient cannot use other medications due to contraindications or intolerance 2

• If an opioid must be used, there is better evidence for butorphanol nasal spray than for hydromorphone specifically for headache treatment 1

Important Cautions

• Medication-overuse headache can result from frequent use of acute medications (more than twice weekly), leading to increasing headache frequency and potentially daily headaches 2

• Rebound headache is associated with withdrawal of analgesics or abortive migraine medication 1

• Acute therapy should be limited to no more than two times per week to guard against medication-overuse headache 1

• Hydromorphone has been commonly implicated in adverse drug events and medication errors 4