What it Takes to Treat Migraine

January 25, 2022

By Annika Ehrlich

When it comes to addressing high blood pressure or attacking asthma, patients often need more than one medication to get their chronic condition under control. So why do insurers push back when my patients with migraine need a similar approach?

Getting to Combination Therapy

Migraine disease is a spectrum that can fluctuate throughout a patient’s lifetime. Just like with other chronic conditions, medications can be used to manage migraine.  

Medications typically fall into two categories – acute and preventive. Acute medications treat active attacks when they occur, whereas preventive medications are taken routinely to lessen attack frequency and severity.

Some patients may have occasional migraine attacks – a few per year, which require occasional use of acute medications, while other patients have a higher burden of disease that requires preventive treatment in addition to acute.

Patients should be offered preventive medications when they start having several days of severe and disabling migraine per month, but we know that’s often not the case. Patients may manage with over the counter or prescribed acute medications, and not fully discuss their symptoms with their providers. Likewise, providers may not be asking patients enough questions about the frequency of attacks or use of acute medications, but they should. Frequent use of acute medications can lead to worsening of migraine over time, resulting in an even greater need for comprehensive, personalized preventive treatment.

People living with migraine typically try one medication at a time, working from established to newer, migraine specific therapies. I counsel my patients that they may need to try several different medications before they find one that works and is well tolerated. And I always share that a combination of medications may be necessary.

When One Medication Isn’t Enough

Effective migraine prevention is defined as a 50% reduction in the frequency and severity of symptoms. If a patient is experiencing 30 headache days a month and a preventive medication gets them down to 15 days, that’s a 50% reduction. But 15 headache days a month still takes a huge toll on patients’ personal lives, finances and work.

Adding a second preventive medicine may knock those 15 days down to seven. Again, that’s better, but seven days of disability a month is still a lot. Patients need effective acute medications to treat these attacks, and may also need other “rescue” medications if their acute medications fail them. This combination helps keep patients out of urgent care and the ER.

Accessing the Right Treatments

The right combination of treatments can make a powerful change in patients’ lives. But getting patients started on multiple medications, specifically newer options, is difficult because of insurers’ red tape.

Public and private insurers alike put a heavy administrative burden on clinical staff to prove their patients need multiple medications. Despite our investment of time to complete forms and provide records, insurance denials are still all too common.

It’s heartbreaking what many patients go through to get to the point of needing multiple treatments, only to be told “no” by their health plan.

Every patient’s combination of medications might look different. But all patients are best served by a comprehensive approach. That’s what keeps them present for their lives and their loved ones.

Policymakers have the power to support a commonsense, financially responsible patient-centered approach to care. When patients with migraine can get timely and appropriate treatment, quality of life goes up, and health care system costs go down.

Annika Ehrlich is nurse practitioner who treats patients with headache disorders at the University of California, San Francisco and is a member of the Alliance for Patient Access.

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