DUR: Over Utilization of Migraine Medications in the Medi-Cal FFS Population
Migraine headaches affect more than 29 million people in the United States.1 It is a debilitating disease, characterized by throbbing head pain, usually located on one side of the head and often accompanied by nausea and sensitivity to light and/or sound.2 The pain is disabling for patients, making it difficult for them to work or perform daily activities. A World Health Organization (WHO) survey rated migraines as one of the most disabling chronic disorders.2
The average age of onset of migraines is during adolescence and most migraines commonly occur between 15 and 55 years of age.1 Women are three times more likely than men to have migraine attacks.
Migraine attacks occur periodically and can last from four to 72 hours.2 Symptoms vary by episode and individual. This can make it difficult for patients to determine if and when to take abortive migraine medications. There are currently seven medications on the market classified as triptans to use as abortive therapy. There are also ergotamine and narcotic pain medications that can be used for acute migraine treatment (typically in combination with abortive therapy). Included with pharmacologic therapy, there are non-pharmacologic measures that can be utilized to help prevent a migraine attack. These include education about the disorder, how migraines occur and changes in lifestyle.2
Patients with any one of the following symptoms should be considered for preventative therapy for migraines: 3, 4
- Two attacks per month, with disability totaling three or more days. If the pain severity is high, then less than two attacks per month should be considered for preventative therapy
- If migraine interferes with normal daily activity
- Use of abortive migraine medications greater than two times per week5
- Abortive medications contraindicated, ineffective or not tolerated
Over utilization of abortive and other acute migraine medications should be discouraged by medical professionals. Patients should be educated on possible consequences when abortive medications are overused, and that rebound migraines can occur. Preventative therapy can assist in decreasing the overall rate of migraine occurrences and decrease the number of emergency room visits for migraine.
Payments to pharmacies in the Medi-Cal fee-for-service (FFS) program for abortive anti-migraine drug therapy, triptans and ergotamine, for the period of October 1, 2005 through September 30, 2006 totaled $6.2 million. Usage of triptans accounted for $5.7 million of that total.
A retrospective study of Medi-Cal FFS beneficiaries (excluding Medicare beneficiaries) with migraines was conducted to determine if patients are over utilizing migraine medications, using preventative medications to control migraine attacks and whether they are frequently using hospital emergency rooms when seeking treatment for their migraines. Patients who were Medi-Cal FFS in 11 out of 12 months during the period of October 2005 through September 2006, and who had two or more paid claims for migraine medications were considered for the study.
| Using decision support software (Identification of Migraine Prevention and Acute Therapy, or IMPACT, developed by Ortho-McNeil Neurologics), 5,787 Medi-Cal beneficiaries met the criteria. | ||
| – | 84 percent of beneficiaries using triptans were female (4,879 out of 5,787). American Migraine Prevalence and Prevention Study (AMPP) data showed 77 percent of participants being female. | |
| – | 47 percent of beneficiaries with migraines were between 46 and 64 years of age. | |
| – | 59 percent of beneficiaries would be considered “high utilizers” due to their use of three or more doses per month of a triptan. This is based on current Department of Health Care Services (DHCS) policy of three dispensings of a triptan prescription for tablets/nasal spray or 10 dispensings of the injectable kit in a 12-month time period. Anything beyond this would be considered a “high utilizer” and would require a Treatment Authorization Request (TAR) for payment. | |
| Further analysis determined that 62 percent of beneficiaries taking migraine medication were also taking some sort of preventative (prophylactic) medication. There are four categories of preventative medication that are commonly used, but only a small number are FDA approved to help prevent migraines. Information on whether these patients are taking the preventative medications for true prevention or just taking it due to a co-morbid disease state is not known. However, even if not taken specifically for prevention, the outcome of decreased migraine occurrences should still occur. | ||
Additionally, of the 7,978 Medi-Cal FFS beneficiaries that had at least one claim for a triptan or an ergotamine in this same time frame, 9 percent had been seen in the emergency room with a diagnosis of migraine. These patients may not be getting satisfactory relief and/or prevention of their migraine episodes, and would be ideal candidates for initiation of or adjustment to their preventative therapy.
Recommendations
Medi-Cal wants to make certain
that beneficiaries that suffer from migraines can get both the
acute treatment needed and the preventative therapy that may be
warranted. The following steps should be followed by all
providers:
- Prescribers should monitor how frequently their patients are experiencing migraines through both consultation with the patient regarding the use of medications and use of patient migraine journals.
- Pharmacists should consult beneficiaries regarding the consequences of over utilization of abortive migraine medication and use of a preventative therapy and should contact the prescriber if over utilization continues without the use of preventative therapy. Pharmacists should also discuss what may be triggering a migraine and how to avoid those triggers.
- For all providers, follow the guidelines on when to initiate preventative therapy for migraine sufferers.
- Lipton R.B. et al, Migraine Prevention Patterns in a Community Sample: Results from the American Migraine Prevalence and Prevention (AMPP) Study. Poster presented at the 2005 annual meeting of the American Headache Society & AMPP Study Fact Sheet.
- Goadsby P.J., Lipton R.B., Ferrari M.D. Migraine – Current Understanding and Treatment. N Engl J Med 2002; 346:257-270.
- Snow V et al, for the American Academy of Family Physicians and the American College of Physicians – American Society of Internal Medicine. Ann Intern Med. 2002; 137:840-849.
- Ramadan NM et al, and the US Headache Consortium. 2000:1-55.
- Silberstein S, Practice Parameter: Evidence-Based Guidelines for Migraine Headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000; 55:754-762.