Current migraine care recommendations do not reflect recent advances in the scientific understanding of migraine disease.
The National Headache Foundation (NHF) has issued new migraine care recommendations challenging health insurance payers for uneven treatment of migraine patients.
The “current care models have not kept pace with the many advances in treatment,” NHF said in a statement.1
Payers should adopt care models that are patient-centric, in which the clinician—in collaboration with the patient—is the primary decision-maker and selects a treatment that addresses the patient’s treatment goals and needs, NHF said.
“Clinicians and patients are naturally upset that payers are forcing them to use older medications, some of which are not even designed for the specific treatment of migraine, even though new migraine-specific therapies now exist,” said Tom Dabertin, NHF CEO and executive director.
“For too long, migraine patients have been treated differently than others with medical issues as it related to prescription medications,” Dabertin added.
The scientific understanding of migraine has advanced considerably in recent years, bringing better tolerated and better-studied treatments to patients, most notably, anti-calcitonin gene-related petptide (CGRP) monoclonal antibodies (mAbs), oral CGRP antagonists (gepants), and agents targeting serotonin receptors, NHF noted.
“There is also growing awareness among clinicians that what was once thought sufficient efficacy for successful migraine control is, in fact, inadequate,” NHF said. “Unfortunately, the care models set by payers and the consequent treatment paradigms have not kept pace with these advances.”
NHF’s position is that the selection of a migraine therapy:
The organization’s specific recommendations are outlined below.
For patients with a minimum of 8 migraine days per month—a number that constitutes high-frequency or chronic migraine—NHF recommends that the clinician have the ability to select the most suitable preventive therapy, with unfettered access to FDA-approved preventive drugs, for the following reasons:
This list of generic drugs includes:
Topiramate, divalproex, sodium valproate, timolol, and propranolol are FDA-approved for migraine prevention. The remaining drugs are commonly used, but not have not been approved for that indication.
“If a drug from this list has failed to provide the patient with benefits in the severity and/or frequency of migraine, or is found to have intolerable side effects, the clinician should be free to select the next most suitable FDA approved preventive therapy, based on the individual patient’s needs and situation,” NHF said.
In the NHF-recommended model for preventive care, a patient is considered to have “tried and been failed by” a given drug if at least 1 of the following applies:
At the time of decision, the patient has a previously documented history of having “tried and been failed by” the drug due to intolerability or lack of treatment benefit.
After a patient has “tried and been failed by” 2 of these generic drugs, the clinician can select another suitable therapy based on patient needs. These therapies include FDA-approved acute agents such as lasmiditan (Reyvow) or a gepant (ubrogepant [Ubrelvy], rimegepant [Nurtec ODT]; or atogepant [Qulipta]).
As with the NHF-recommended preventive care model, a patient is considered to have “tried and been failed by” a drug for acute migraine if at least 1 of the following applies:
1. National Headache Foundation position statement on the treatment of migraine. National Headache Foundation. January 19, 2022. Accessed January 20, 2022. https://headaches.org/2022/01/19/national-headache-foundation-position-statement-on-the-treatment-of-migraine/