Migraines affect 12% of adults in the United States, according to the American Migraine Foundation. In workers’ comp, certain workplace injuries may exacerbate preexisting migraine conditions, and it has also been suggested that traumatic brain injury (TBI) may be a risk factor for migraines.
Since 2019, several novel migraine agents have entered the market, and despite high costs these novel agents are now considered among first-line treatments for migraine therapy by the American Headache Society.
It appears these novel migraine agents are making a real and growing impact on workers’ comp pharmacy spend.
The California Workers’ Compensation Institute (CWCI) published a new report on trends in the utilization and reimbursement of migraine drugs in the California workers’ comp system. This study was based on data from the CWCI’s Industry Research Information System (IRIS) database which contains details on more than 9.5 million California workers’ comp prescriptions filled between 2010 and 2023.
Migraine drugs did not rank among the top 10 drug groups in California workers’ comp a decade ago, but now rank sixth in terms of total payments, with aggregate expenditures approaching those of opioids and surpassing those of antidepressants and musculoskeletal drugs.
Migraine drugs made 0.7% of prescriptions for California injured workers in 2023, up nearly four-fold from 0.2% in 2018. As for costs, these drugs accounted for 4.7% of workers' comp drug costs, up from 0.6% in 2018, an eight-fold increase.
The top two migraine drugs prescribed in 2023 were the relatively inexpensive sumatriptan (Imitrex) and rizatriptan benzoate (Maxalt), which are used to relieve migraine symptoms. In 2018, these drugs made up 75.6% of migraine drug prescriptions, dropping to 52.3% in 2023. In the same timeframe, their share of migraine drug spend fell from 38.0% to 5.5%.
Over that same period, the study identified six cost-driver migraine drugs that were approved by the FDA and introduced into the system, but are categorized as Not Listed drugs in the MTUS Formulary:
- Aimovig Autoinjector: Approved in May 2018, its share of migraine prescriptions dropped to 5.7% in 2023, but it still represented 6.7% of drug costs, with an average payment of $708
- Ajovy: Its prescription share of migraine drugs reached 4.6% in 2023, but its cost share fell to 6.7% with the introduction of higher cost alternatives, despite an average payment of $817
- Emgality: This drug represented 2.6% of migraine prescriptions and 2.8% of costs in 2023, with an average payment of $649
- Ubrelvy: Its migraine prescription share grew to 7% in 2023, with costs rising to $1,507 per prescription
- Nurtec ODT: This drug saw rapid growth, reaching 15% of migraine prescriptions and 41.6% of migraine drug costs in 2023, with an average payment of $1,675. Making this the fastest growing migraine drug in California’s workers’ comp system in utilization and payments
- Qulipta: Newer to the market in 2023 for chronic migraines, it accounted for 3.1% of migraine prescriptions and 5.7% of costs in 2023, with an average reimbursement of $1,106
Outside of California, similar trends were noted by the WCRI. In the fifth edition of their reports on interstate variation and trends in workers’ comp drug payments, the WCRI found that migraine medications accounted for 7-15% of prescription payments in the top quartile of 28 study states as of 2023. Per-claim payments for migraine medications increased in 23 of the 28 study states, and in the 28-state median, migraine medications made up 3% of prescription payments.
While novel migraine agents can offer a significant benefit for certain patients, other more cost-effective medications, such as beta blockers and topiramate, may be considered based on individual patient factors and clinical features.
This is particularly important as these novel migraine agents can be significantly expensive. The first FDA-approved CGRP inhibitor drug, Aimovig (erenumab), was released in 2018 with a list price of $6,900 per year. According to a BioDrugs study, the costs of the new migraine drugs can be considered “high in principle when compared with SOC [standard of care].” Forbes also notes, “The costs of novel migraine treatments are considerably higher than generic triptans and most other migraine therapies.”
