Morphine Should Not Be Used for Headache Treatment
Morphine is not recommended for headache management and should be reserved only as a last-resort option when all other evidence-based treatments have failed, contraindications exist, sedation is acceptable, and abuse risk has been addressed. 1
Why Morphine Is Inappropriate for Headache Treatment
Guideline Recommendations Against Opioid Use
The American College of Physicians explicitly states that opioids (including morphine) 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
Current headache treatment guidelines consistently recommend against opioids as first-line, second-line, or even routine rescue therapy for migraine and other headache types. 1
The American Academy of Family Physicians recommends avoiding medications containing opiates as they lead to dependency, rebound headaches, and eventual loss of efficacy, particularly in chronic daily headaches. 1
Evidence of Poor Efficacy
A 1996 placebo-controlled trial demonstrated that morphine was no more effective than placebo in relieving migraine attacks and provoked severe side effects. 2
When morphine was compared to dexamethasone for acute migraine in the emergency department, morphine was significantly inferior at both 1 hour and 24 hours after administration. 3
Research comparing morphine to paracetamol (acetaminophen) for post-traumatic headache found that paracetamol provided significantly faster and more effective pain relief (37 minutes vs 72 minutes mean treatment duration). 4
Clinical Harms and Risks
Medication-overuse headache can result from frequent opioid use (more than twice weekly), leading to increasing headache frequency and potentially daily headaches. 1
Opioids carry significant risks of dependency, rebound headaches, and eventual loss of efficacy. 1
Despite limited endorsement by consensus guidelines, opioid use for headaches in US emergency departments increased dramatically between 2001-2010, with morphine prescribing increasing substantially during this period—representing inappropriate practice patterns. 5
What Should Be Used Instead
First-Line Treatment Algorithm
For mild to moderate headaches: Start with NSAIDs (ibuprofen 400-800 mg, naproxen 500-825 mg, or aspirin 1000 mg) or acetaminophen 1000 mg. 1
For moderate to severe headaches: Use combination therapy with a triptan PLUS an NSAID, which is superior to either agent alone. 1
Add an antiemetic (metoclopramide 10 mg IV or prochlorperazine 10 mg IV) for patients with nausea or when additional analgesia is needed, as these provide direct analgesic effects beyond treating nausea. 1
Parenteral Options for Severe Headache
The optimal IV "headache cocktail" consists of metoclopramide 10 mg IV plus ketorolac 30 mg IV, providing rapid pain relief while minimizing side effects and rebound headache risk. 1
Subcutaneous sumatriptan 6 mg provides the most rapid and effective relief for severe migraine, with 59% achieving complete pain relief by 2 hours. 1
Dihydroergotamine (DHE) has good evidence for efficacy and safety as monotherapy for acute migraine attacks. 1
Critical Frequency Limitation
Limit all acute headache medications to no more than 2 days per week to prevent medication-overuse headache. 1
If patients require acute treatment more frequently than twice weekly, initiate preventive therapy immediately rather than increasing frequency of acute medications. 1
Special Populations
Pregnancy Considerations
Opioids and butalbital-containing medications should not be used during pregnancy due to risks of dependency, rebound headaches, and potential fetal harm. 6
Acetaminophen 1000 mg is the first-line medication for acute headache treatment during pregnancy. 6
Metoclopramide is safe and effective for migraine-associated nausea during pregnancy, particularly in the second and third trimesters. 6
Common Pitfalls to Avoid
Do not allow patients to establish patterns of frequent opioid use for headache management—this creates a vicious cycle of medication-overuse headache requiring transition to preventive therapy. 1
Do not prescribe morphine simply because other treatments provided incomplete relief after a single trial—failure of one triptan does not predict failure of others, and multiple evidence-based options should be exhausted first. 1
Avoid the misconception that "stronger" pain medication (like morphine) is needed for severe headaches—the evidence shows that migraine-specific treatments (triptans, DHE) and dopamine antagonists (metoclopramide, prochlorperazine) are more effective than opioids. 7