Calcitonin gene-related peptide (CGRP) receptor antagonists for migraine prophylaxis
Coverage Decision
CGRP antagonists for migraine prophylaxis require prior authorization for coverage.
Criteria for initial 90-day trial:
- Diagnosis of chronic migraine, defined as headache on ≥ 15 days per month for > 3 months, which has the features of migraine headache on ≥ 8 days per month.
- Migraine diagnosis is causally related to an accepted industrial injury or occupational disease.
- The patient has kept a daily headache diary for at least 3 months prior to confirm diagnosis and establish baseline frequency, duration and quality of headaches.
- The patient has been screened for medication overuse headache, defined by the use of triptans for 10 or more days per month and/or the use of analgesics for 15 or more days per month. If present, discontinuation of the suspected medication(s) is recommended for 2 months.
- The patient has tried and failed at least 3 preferred prophylaxis drugs from at least 2 different classes (unless contraindicated):
- Anticonvulsants: divalproex sodium/valproate, topiramate
- Beta-blockers: metoprolol, propranolol, timolol
- Antidepressants: amitriptyline, venlafaxine
- The patient has not received botulinumtoxinA (Botox) injections for migraine prophylaxis in the previous 12 weeks, and will not receive it or other CGRP antagonists concurrently with approval.
- There are no contraindications to the use of CGRP antagonists: history of adverse reactions or hypersensitivity to the medication or any component thereof.
- CGRP antagonists are part of an agreed upon, time-limited, rehabilitative treatment plan with clearly stated treatment goals (e.g., participation in vocational rehabilitation and/or return to work).
Criteria for continued coverage:
- No serious adverse events experienced from treatment with CGRP antagonists.
- Migraine days per month are reduced by at least 50% from baseline.
- Use of the CGRP antagonist resulted in documented rehabilitative benefit.
References:
- Cutrer, FM. Pathophysiology, clinical manifestations, and diagnosis of migraine in adults. UpToDate. https://www.uptodate.com (accessed on Dec 06, 2019).
- Henson B, Hollingsworth H, Nevois E, Herndon C. Calcitonin Gene-Related Peptide (CGRP) Antagonists and Their Use in Migraines. J Pain Palliat Care Pharmacother. 2019;Nov 25:1-10.
- Silberstein SD, Holland S, Freitag F, Dodick DW, Argoff C, Ashman E. Evidence-based guideline update: pharmacologic treatment for episodic migraine prevention in adults: report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology. 2012;78:1337-45.
- Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016;86(19):1818-26.
- Steiner TJ, Jensen R, Katsarava Z, et al. Aids to management of headache disorders in primary care (2nd edition). J Headache Pain. 2019;20,57.
- Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38(1):1-211.