2018
Aimovig®
(erenumab-aooe)
autoinjector
A recent trend in drug therapy is the rise of calcitonin gene-related peptide (CGRP) receptor antagonists for the treatment and prevention of migraines.
A relatively new class of drugs, the first CGRP antagonist was approved in 2018, with several more approved in the following years. As newer medications, CGRP antagonists come with high costs, and their wide adoption in the market has directly impacted workers’ comp, contributing to year-over-year increases in cost per script and cost per claim for migraine therapies.1
This trend is not expected to change course, especially when considering the revised treatment recommendations by the American Headache Society in March 2024, which include CGRP antagonists as first-line treatment for the prevention of migraines.2
According to the Workers Compensation Research Institute (WCRI) per-claim payments for migraine medications increased in 23 states from 2021-2023, averaging 3% of drug spend across the country, but as high as 7-15% in some states.3
Looking into individual states helps provide more nuance to this trend, as the California workers’ comp system saw migraine drug prescriptions increase four-fold from 2018-2023, while drug spend for migraine agents increased eight-fold. The increases in drug spend were tied to six CGRP antagonists, with average payments ranging from approximately $649 to $1,675 per prescription.4 For context, most CGRP antagonists used for migraine prevention are monthly injections, while those used for acute treatment are taken as needed, meaning there could be fluctuations in prescriptions over time.
Nurtec ODT, Ubrelvy and Aimovig have comprised the majority of migraine therapy spend over the last three years, with Qulipta tablets contributing to an increasing share over the last year.1
In workers comp, migraines can be caused or exacerbated by various workplace injuries, including traumatic brain injuries.5-6 It is essential to recognize the cause and address the impact of migraines, as they can significantly affect injured worker recovery, return to work, and productivity.
The definition and recognized symptoms of migraines vary across different medical organizations, especially as there are several different types of migraine conditions. The National Institutes of Health define migraines as powerful headaches with a moderate to severe throbbing pain that chronically return, sometimes accompanied by aura – which can include changes in vision or the ability to speak – as well as fatigue, nausea, and vomiting.7
For many, migraines are a genetic disorder, though they can be triggered by hormonal changes, environmental factors, and certain medications.
When experiencing migraines, individuals have been found to have higher levels of CGRPs in their blood, and it is theorized that blocking CGRPs can reduce or limit migraine activity.8 Since 2018, several medications that block CGRP have been approved for the treatment and/or prevention of migraines.
For some individuals, migraines can be managed without medications. If an individual’s migraines are specifically triggered by factors that can be controlled – such as substance use, lack of sleep, certain stimuli, etc. – then drug therapy may not be required. Furthermore, certain non-pharmacological approaches – including special diets, supplements, yoga, acupuncture, and more – may help to prevent or reduce migraine attacks.
However, many patients still require drug therapy, making it important to understand the various migraine medications available, including CGRP antagonists. Some medications are used for the prevention of migraines, while others are acute treatments. Each medication comes with different factors to consider, and selection depends upon patient-specific factors.
Several different types of medications are considered safe and effective first-line therapies for the prevention of migraines.
These include:
Each of these drug classes comes with potential side effects, adverse events, and drug-drug or drug-disease interactions to consider. Selection of medication should be based on individual patient factors.
However, specific considerations to point out with respect to workers’ comp populations include:
There are several drug classes considered safe and effective first-line therapies for the acute treatment of migraines, including:
Once more, these different drug classes come with different possible side effects, adverse events, and drug-drug or drug-disease interactions to consider. For example, triptans are contraindicated in patients with uncontrolled high blood pressure.
Due to changes in treatment recommendations by the American Headache Society in early 2024, CGRP receptor antagonists are among a list of first-line therapies for the prevention of migraines. They are considered safe and effective when properly utilized.
CGRP antagonists provide an additional option for patients for the prevention of migraines. Like other migraine therapies, patient-specific factors still come into play.
A study from the European Journal of Neurology explored the effectiveness of CGRP antagonists prescribed to prevent migraines. While the CGRP antagonists outperformed beta blockers as a preventive medication, patients taking those CGRP antagonists ended up increasing their triptan prescriptions – meaning they ended up taking more medication for the acute treatment of migraines when the CGRP antagonists could not prevent them.9
It is important to note that CGRP antagonist medications come with risks and precautions of their own. Aimovig for instance, should be used with caution in patients with pre-hypertension or hypertension due to risk of increased blood pressure. Prescribers should monitor blood pressure at treatment onset and throughout treatment.
In some cases, these drugs may not be considered appropriate, while in others they could offer a safer alternative.
While marijuana is far from a first-line therapy for the treatment of migraines, several states have medical marijuana programs where migraines are considered a qualifying condition for marijuana therapy. This includes:
While medical marijuana is primarily used when other therapies have failed, some patients may be utilizing medical marijuana for the treatment of migraines. Additionally, some states feature discretionary language allowing providers to recommend marijuana when they see fit.
The rapid and significant growth of workers’ comp prescription drug spend in the migraine therapy category has the attention of the industry, and especially medical program managers. PBM partners can play an important role in addressing this trend by:
