Who Is Prescribing Opioids for Kids With Headache?

William T. Basco, Jr., MD, MS


March 29, 2019

Opioids for Pediatric Headache

Regardless of headache type (migraine or tension), current national recommendations discourage the use of opioids for pediatric primary headache disorders. Adolescents in particular are at high risk for opioid misuse, which often begins with a medical prescription for opioids.[1] Little is known, however, about the frequency of opioid prescribing for pediatric headache.

Meckler and colleagues[2] evaluated opioid prescribing and dispensing for children and adolescents in ambulatory and emergency department (ED) settings. A Washington State Medicaid dataset for children aged 7-12 years and adolescents aged 13-17 years was paired with the state's prescription drug monitoring program data for this analysis.

The study cohort included 8878 ED visits and more than 42,000 ambulatory visits with a primary diagnosis of headache, 30% of which were conducted by a pediatric provider. Overall, 1.5% of headache visits resulted in a prescription for opioids. However, the rate of opioid prescribing in the ED (3.9%) was higher than the 1% rate of prescribing for all ambulatory settings combined. The mean dose of opioid dispensed in the ambulatory setting was 103.5 morphine mg equivalents (MMEs) per day compared with 73 MMEs per day for opioids dispensed after an ED visit.

Hydrocodone was the most common opioid prescribed (54%), followed by codeine (38%) and oxycodone (8%). Regardless of setting, opioids were less often prescribed by pediatric providers. No differences were found in opioid prescribing rates by patient sex, and older teens (13-17 years) with headache were slightly more likely to receive an opioid prescription than were preteens (7-12 years).

A hint of a silver lining was seen in an overall decline in opioid prescribing for pediatric headache from 2012 to 2015. Although rates of opioid prescribing for pediatric headache are generally low, the higher rates seen in the ED and in conjunction with visits to nonpediatric providers suggest opportunities for intervention.


The finding of a low rate of opioid prescribing for kids with headache is good news, but even at a low rate, opioids are prescribed to thousands of children annually. The study authors point out several issues with evaluating opioid prescribing. First, many other studies have shown a general decline in opioid prescribing for children in the past decade.

That's good news, but the frequency of prescription is only part of the issue. Focusing on whether the prescriptions are appropriate in the first place is important.

This study also shows another aspect of the opioid epidemic that is not revealed in looking at overall prescribing rates: the daily dose delivered. Current recommendations for patients of all ages suggest cautious prescribing (≥ 50 MMEs/day) and reserving doses ≥ 90 MMEs per day for opioid-dependent patients. So it stands to reason that we should be even more judicious for kids.

The fact that the daily dose delivered in the ambulatory setting averaged more than 100 MMEs/day and more than 70 MMEs/day in the ED setting is concerning. Opioid-naive patients, particularly children, should not need such high doses. Paying attention to the daily dose delivered is another opportunity for opioid stewardship.


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