Despite guidelines directing against the use of opioids in migraine management, this analysis by Lipton et al.1 reveals that more than 36% of patients surveyed have opioids available to them. These opioid users were more likely to have allodynia and vascular risk factors including diabetes, moderate-to-severe depression, anxiety, obesity, and high MIDAS scores, and they were more likely to be men. The data in this study demonstrate that those who use opioids are worse off in many domains, but the casual directions cannot be determined. Do opioids actually make migraine worse or do the most severe patients get prescribed opioids? Is the increased use of opioids a consequence of increased headache with high MIDAS scores, central sensitization, and allodynia? This leads to a debate on which came first, and it is likely that worsening headache came first,2 leading to initial opioid use. However, did the opioids subsequently worsen and escalate the situation? A controversial concept is whether opioids have a place in migraine treatment at all, given the new treatment options (Gepants and devices) because these have not been identified as causing medication overuse. Is the real issue a lack of education about alternative treatment options, resulting in patients becoming opioid users because of misdiagnosis and poor prescribing of migraine-specific medications?