Drug Therapy for Acute Treatment of Migraine Headache

Coverage Decision

Analgesics, such as acetaminophen and NSAIDs, should be considered drugs of choice for acute treatment of mild to moderate migraine headaches without vomiting or severe nausea.

Triptans, calcitonin gene-related peptide (CGRP) antagonists and ditans require prior authorization for the acute treatment of migraine headaches that are causally related to an industrial injury or occupational disease:

  • Triptans
    Triptans have an established record of safety and efficacy and are considered first-line agents. Generic triptans are coverable upon request.
  • CGRP Antagonists
    Due to a lack of long-term safety and efficacy data and comparative evidence versus triptans, rimegepant and ubrogepant are considered second-line agents. The coverage of CGRP antagonists requires previous trials of at least two triptans, unless the patient has a contraindication to their use.
  • Ditans
    Lasmiditan lacks long-term safety and efficacy data and comparative evidence versus triptans. In addition, lasmiditan is associated with central nervous system side effects, such as drowsiness and dizziness, and is a controlled substance. As such, ditans are considered third-line agents and require previous trials of at least two triptans and at least one CGRP antagonist, unless trials are contraindicated.

Prescribing of drug therapy for acute treatment of migraine headaches should be consistent with FDA-recommended dosing guidelines and contraindications to use and should account for other patient-specific factors.

References:

  1. American Headache Society. The American Headache Society Position Statement On Integrating New Migraine Treatments Into Clinical Practice. Headache 2019; 59:1-18.
  2. Crop R, Goadsby PJ, Stock DA, et al. Efficacy, safety, and tolerability of rimegepant orally disintegrating tablet for the acute treatment of migraine: a randomized, phase 3, double-blind, placebo-controlled trial. Lancet 2019; 394:737-45.
  3. Dodick DW, Lipton RB, Ailani J, et al. Ubrogepant for the Treatment of Migraine. N Engl J Med 2019; 381:2230-41.
  4. Goadsby PJ, Wietecha LA, Dennehy EB, et al. Phase 3 randomized, placebo-controlled, double-blind study of lasmiditan for acute treatment of migraine. Brain 2019; 142:1894-1904.
  5. Institute for Clinical and Economic Review (ICER). Acute Treatments for Migraine: Final Policy Recommendations. February 25, 2020.
  6. Kuca B, Silberstein SD, Wietecha L, et al. Lasmiditan is an effective acute treatment for migraine: A phase 3 randomized study. Neurology 2018; 91:e2222-32.
  7. Lipton RB, Croop R, Stock EG, et al. Rimegepant, an Oral Calcitonin Gene-Related Peptide Receptor Antagonist, for Migraine. N Engl J Med 2019; 381:142-9.
  8. Lipton RB, Dodick DW, Ailani J, et al. Effect of Ubrogepant vs Placebo on Pain and the Most Bothersome Associated Symptom in the Acute Treatment of Migraine: The ACHIEVE II Randomized Clinical Trial. JAMA 2019; 322:1887-98.
  9. Oswald JC, Schuster NM. Lasmiditan for the treatment of acute migraine: a review and potential role in clinical practice. J Pain Res 2018; 11:2221-7.
  10. https://www.uptodate.com/contents/acute-treatment-of-migraine-in-adults (Accessed on May 15, 2020).