Financial Burdens to Migraine Treatment

A 2018 study by Bonafede et al4 reported that increased use of acute medications, such as opioids and triptans, and frequent emergency room visits for migraine substantially increased total healthcare costs for patients with migraine. Patients without health insurance may seek less medical care outside of the United States, Dr Monteith explained. “High deductibles may also be a problem, as patients may be unwilling to try certain in-hospital treatments until they meet their deductibles.” She also noted the existence of a form of pseudo-insurance, whereby patients may have adequate insurance but with too many restrictions before they can receive high-quality treatments. “This can frustrate both the doctor and patient and result in negative health outcomes,” she said.

Dr Robbins elaborated on the challenges to getting insurers to cover the best available treatments, even for those who have adequate coverage. “Newer treatments such as calcitonin gene-related peptide antibodies and neuromodulation devices are expensive and not yet widely covered by all insurances, particularly with government-sponsored programs,” he said. “Fortunately, botulinum toxin injections generally are covered and are a first-line preventive treatment for chronic migraine.” He noted additional challenges: “Patients with migraine, and chronic migraine in particular, often have multiple comorbidities that require treatment, which adds to burden, cost, and frustration. Social Security still does not recognize migraine or chronic migraine as a disabling condition despite advocacy efforts.”

Approaches to Treatment for the Underinsured

For patients with migraine who are unable to afford high-cost treatments, pain can still be managed through a combination of OTCs, older, less expensive pharmacologic therapies, and nonpharmacologic approaches. Dr Monteith cited benefits to trying nondrug approaches, such as

·acupuncture;

·vitamins and supplements;

·lifestyle modifications;

·trigger management (eg US Food and Drug Administration-approved glasses for light sensitivity); and

·psychological interventions, including apps for relaxation therapy, meditation, and so on.

“Cheaper preventive treatments include beta blockers and tricyclic antidepressants, and patients may also obtain nonsteroidal anti-inflammatories, menthols, and even sumatriptan out of pocket for reasonable costs in some places,” she said.

Dr Robbins agreed with this approach. “Fortunately, there remain many medication and nonmedication therapies for migraine that are much less costly than some of the newer treatments,” he said. “Unfortunately, access to adequate quantities of medication and treatments in general seems ironically easier for therapies that have more evidence for harm, such as opioids and barbiturates, rather than therapies that have more evidence for benefit, such as triptans, preventive treatments, and behavioral treatments,” he added.

Disclosures

Dr Monteith reports grants and personal fees from Eli Lilly, Allergan, and Teva Pharmaceuticals outside the reported work, and has done advisory work for ElectroCore, Supernus, and Promius.

Dr Robbins has received research support from eNeura, serves in editorial capacities for Headache and Current Pain and Headache Reports, and has received book royalties from Wiley.

Follow @ClinicalPainAdv

References

1. Lipton RB, Serrano D, Holland S, Fanning KM, Reed ML, Buse DC. Barriers to the diagnosis and treatment of migraine: effects of sex, income, and headache features. Headache. 2013;53:81-92. Abstract

2. Dodick DW, Loder EW, Manack Adams A, et al. Assessing barriers to chronic migraine consultation, diagnosis, and treatment: results from the chronic migraine epidemiology and outcomes (CaMEO) study. Headache. 2016;56:821-834.

3. Charleston L 4th, Royce J, Monteith TS, et al. Migraine care challenges and strategies in US uninsured and underinsured adults: a narrative review, part 2. Headache. 2018;58:633-647.

4. Bonafede M, Cai Q, Cappell K, et al. Factors associated with direct health care costs among patients with migraine. J Manag Care Spec Pharm. 2017;23:1169-1176.

This article originally appeared on Neurology Advisor