It also can be extremely expensive and may not be covered by insurance.”[21] Because the value of

migraine surgery is still uncertain, the AHS and the Choosing Wisely Task force believe that patients should undergo such treatment only in the context of properly designed clinical trials that are aimed at developing good quality evidence about the harms and benefits of treatment. 4.  Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk VX-770 solubility dmso for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened ICG-001 solubility dmso sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should

be monitored for the development of chronic headache.[22-25] This recommendation is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. Rather, it is meant to address the appropriate order in which medication classes should typically be used. The American Academy of Neurology Five Things List includes a similar recommendation “Don’t use opioid old or butalbital treatment for migraine except as a last resort.”[26] In the membership survey, the overuse of butalbital-containing and opioid medications was identified as a common problem. The committee felt there is strong evidence that these should be avoided as first-line treatment in all recurrent

headache disorders, not just migraine. Although treatment for individual headaches is used intermittently, the primary recurrent headache disorders (of which migraine, tension-type, and cluster headache are the most common) are conditions of long duration for which such treatment will be used repetitively over many years. Risks and harms that are unimportant in treating a single attack can become important when treatment is used for long periods of time. Once established, medication overuse can be difficult to treat and recidivism is common. Thus, treatments such as triptans or nonsteroidal anti-inflammatory drugs, which are not associated with dependence or sedation, are preferred first-line. The committee recognized, however, that there are many clinical situations in which the use of these treatments is appropriate, including some situations where they are first-line treatments. These include patients for whom triptans or nonsteroidal anti-inflammatory drugs are contraindicated or ineffective. 5.  Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.