What a worker’s experience of unjustified dismissal tells us about the management of migraine in New Zealand.
On 20 April 2022, the New Zealand Herald reported on a story about a mechanical technician, Shane Hawkins, who was awarded compensation for unjustified dismissal due to his persistent and debilitating migraine attacks.
Two aspects of this story are worth considering in more detail. In the report, Hawkins told the company he worked for that he “often took prescribed codeine to manage the pain” and he “provided a letter from his doctor confirming his use of paracetamol/codeine for migraine headaches”. This letter was important so the company knew he might test “non-negative” for opiates if drug tested.
When Hawkins woke with a migraine, he would have to call his manager to say he would be late to work, as he needed to wait for the pain medication to take effect. This was happening at least once a month but as often as once a week, to the point that Hawkins had used up all of his sick leave and had to take unpaid leave for absences.
The doctor was reported to have said that the medication “did not raise any significant safety concerns from an employment perspective”. However, the doctor obviously failed to recognise that the use of codeine raises significant safety issues from a migraine management perspective.
Clinical guidelines from around the world universally recommend that opioids (including codeine) should not be routinely used in the treatment of acute migraine attacks. This is for a whole host of reasons: opioids can aggravate the nausea and vomiting associated with migraine, they can reduce the absorption of other medications taken for pain relief, they’re addictive, they’re dangerous in overdose, they’re not as effective as other treatments (such as anti-inflammatory medicines and triptans, which are migraine-specific pain relievers). Most importantly, they can actually make headaches more frequent and severe through their ability to increase sensitivity to pain, and they come with a high risk of tipping people into chronic migraine and medication overuse headache.
The recommended first-Iine treatments for acute migraine attacks are triptans and non-steroidal anti-inflammatory drugs (NSAIDs, e.g. aspirin, ibuprofen, naproxen). Hawkins’ doctor, by prescribing codeine, may in fact have made Hawkins’ migraine attacks more persistent and severe, exacerbating his workplace difficulties. Perhaps Hawkins was unable to take triptans or NSAIDs, or perhaps they didn’t work well for him. In this case, and with migraine attacks occurring as often as once a week, his doctor should have considered prescribing a preventive medication (if Shane wasn’t already taking a preventer), rather than relying on codeine for treatment of acute attacks. Most preventive medications reduce migraine attacks by around 50%, and this may have been enough to keep Hawkins in his job.
We need to raise awareness of the risks and harms from regular use of opioids in the treatment of acute migraine attacks, amongst health professionals as well as patients. Taking regular opioids for migraine is a measure of last resort and needs to be overseen by a pain management specialist, not a primary care physician.
The other aspect of the story that’s notable is that Hawkins informed the company that he suffered from recurrent migraine attacks before he was employed, but the general manager was accommodating and able to work around Hawkins’ occasional lateness. It appears that it was only when this manager resigned, and the owners of the company took over this role, that the problems for Hawkins arose.
Hawkins did the right thing by disclosing that he had a medical condition that could affect his ability to work. It’s commendable that his manager was so understanding and adaptable, and this shows what is possible even within a highly structured and time-constrained industry. But it’s disappointing that subsequent managers were not willing to continue with the flexible arrangements established by the previous manager.
Much more can be done to support people with migraine and other disabling conditions to participate more fully in the workplace. We shouldn’t have to rely on luck in finding an understanding manager; all employers should be able to accommodate people with a level of disability, given that one in five people of working age in New Zealand have some form of disability. Hawkins’ employer missed out on the benefits that come from being a disability-confident organisation, which is a far greater loss than the compensation payment they had to make for Hawkins’ unjustified dismissal.
- Migraine medication options in New Zealand
- Employment for disabled people, Employment New Zealand – resources on becoming a disability-confident organisation in NZ, including reasonable accommodation measures
- Migraine at Work – US based resources about managing migraine at work
- Diagnosing and managing headache in adults in primary care. BPAC NZ. 2017.
- Headaches in over 12s: diagnosis and management. Clinical guideline. NICE (UK). 2012.
- Pharmacological management of migraine (SIGN 155): A national clinical guideline. Scottish Intercollegiate Guidelines Network (SIGN). 2018.
- Canadian Headache Society Guideline: acute drug therapy for migraine headache. Worthington, et al. 2013.
- Migraine management. Australian Prescriber (NPS MedicineWise). 2020.
- Opioids for migraine treatment: use with extreme caution. Department of Health Victoria. 2014.
- Choosing Wisely in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question. American Headache Society and Choosing Wisely. 2013