A recent article in the Journal of Head and Face Pain outlines strategies for migraine treatment without face-to-face visits, and describes ways health insurance companies can remove barriers to migraine care during the coronavirus disease 2019 (COVID-19) pandemic.
A recent article in the Journal of Head and Face Pain outlines strategies for migraine treatment absent of in-person visits, and describes ways health insurance companies can remove barriers to migraine care during the coronavirus disease 2019 (COVID-19) pandemic.
“Our common goal as health care providers is to maximize the health and safety of our patients,” authors write. They continue, “successful management of migraine with avoidance of in‐person clinic and emergency department visits further benefits the current urgent societal goal of maintaining social distance to contain the COVID‐19 pandemic.”
Even with available treatment, migraine accounts for thousands of dollars of lost productivity. In 2018, excess medical and pharmacy treatment costs for employees with migraine averaged to almost $2000 a year. Those treated for migraine also had an average 2.2 more sick days per year, averaging out to approximately $600 in wages and benefits.
In the article, researchers called on insurers to remove requests for prior authorizations and step therapy requirements for migraine therapies, and reviewed classes of different medicine categories to aid providers in their shift to telehealth services during COVID-19.
“Migraine can worsen during times of stress, so having available options that bypass insurance hurdles and can be administered at home without patient training is imperative,” authors argue.
Telemedicine has proven to be a cost-effective and convenient method of providing headache care, historically achieving similar satisfaction rates and outcomes reported from in-person visits. Implementation of telehealth allows individuals living in rural areas, perhaps miles from the nearest headache specialists, to have a clinical encounter over their smartphone. As telehealth parity laws vary per state prohibiting some aspects of care, authors point out telephone visits could function as practical alternatives.
“Patients no longer have to miss work, drive long distances, spend money on gas, tolls, and parking lots, and wait prolonged periods in a doctor's office to be seen, where they might also be exposed to communicable diseases,” authors said, adding they hope widespread use of telehealth will remain after the pandemic has resolved.
COVID-19 continues to take an economic toll on the United States. As a result, pharmacological treatment access may be limited for migraineurs who lost their job and health insurance, or who can no longer afford their migraine medications. Due to these unprecedented circumstances, authors argue insurance providers should minimize or eliminate copays for migraine medications.
“While it may seem unthinkable to ask insurers to pay additional money for these therapies as other health care costs increase, multiple pharmacoeconomic studies have demonstrated that coverage of expensive migraine medications is actually cost‐saving, as it decreases disability and reliance on hospital care,” researchers explain.
Authors note use of nonsteroidal anti-inflammatory drugs (NSAIDs), triptans, and neuroleptics can be used in combination therapy as needed. However, medications within the same drug category should not be combined.
Although NSAIDs, triptans, and anti-emetics are endorsed by the American Headache Society Guideline as acute migraine treatments, authors highlight several treatments recently approved or cleared by the FDA. These include gepants (ubrogepant, rimegepant), lasmiditan, and neuromodulation devices (remote electrical neuromodulation, external trigeminal neurostimulation, single-pulse transcranial magnetic stimulation, external vagal stimulation devices).
Authors also include assessments of several “bridge” strategies to help break severe or continuous pain cycles, although very few therapies have been studied in this classification. “Given the immediate need to support social distancing and keep patients out of the hospital, we feel there is benefit in trying these agents if deemed clinically appropriate, even if the evidence is not fully established,” researchers state.
NSAIDs, such as indomethacin, ketorolac, naproxen, nabumetone, diclofenac, and mefenamic are commonly used as bridge strategies in addition to neuroleptics, triptans, anti-epileptics, and corticosteroids. Authors caution recommendations for certain medications may change as the understanding of COVID-19 pathophysiology and symptoms evolve.
In addition, they encourage providers to avoid the use of opioids and butalbital, as “headaches treated with opioids have a high recurrence rate after the initial analgesic effect, and opioids may exert a pro‐nociceptive state that may prevent the reversal of central sensitization following a migraine attack.”
Given the close contact necessary to administer an injection of onabotulinumtoxinA, researchers urge providers to utilize other migraine preventive treatments first, if possible. These include calcitonin gene-related peptide (CGRP) and CGRP receptor antagonist monoclonal antibodies (mAbs), angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs), melatonin, and zonisamide.
For FDA-approved evidence-based therapies, migraine preventive prior authorization restrictions ought to be lifted to facilitate quick and easy access to medications, researchers state. Insurers should also loosen restrictions on the use of acute and preventive medication for adolescents.
“The COVID‐19 pandemic highlights significant weaknesses in our health care system and has left clinicians and patients scrambling to find solutions to maintain health that for many may have taken years to achieve,” authors conclude. “We, headache specialists, make a plea to insurers to lift cumbersome restrictions to allow patients greater availability of evidence‐based treatment options to reduce the burden of their disease.”
Szperka CL, Ailani J, Barmherzig R, et al. Migraine care in the era of COVID-19: Clinical pearls and plea to insurers. Headache. Published online March 30, 2020. doi:10.1111/head.13810