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:

  1. 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.
  2. Migraine diagnosis is causally related to an accepted industrial injury or occupational disease.
  3. 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.
  4. 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.
  5. The patient has tried and failed at least 3 preferred prophylaxis drugs from at least 2 different classes (unless contraindicated):
    1. Anticonvulsants: divalproex sodium/valproate, topiramate
    2. Beta-blockers: metoprolol, propranolol, timolol
    3. Antidepressants: amitriptyline, venlafaxine
  6. 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.
  7. There are no contraindications to the use of CGRP antagonists: history of adverse reactions or hypersensitivity to the medication or any component thereof.
  8. 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:

  1. No serious adverse events experienced from treatment with CGRP antagonists.
  2. Migraine days per month are reduced by at least 50% from baseline.
  3. Use of the CGRP antagonist resulted in documented rehabilitative benefit.


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