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Comp industry wary of rise of migraine meds


Costly prescriptions to treat neurologically caused migraines comprise the only drug class on the rise in workers compensation, driven by new drugs and the fact that migraines are common among the populace.

A drug trends report released April 30 by Enlyte LLC showed declines in the prescribing of medications to injured workers across the board with one notable exception: migraine medications, which jumped 17% in utilization and 10.2% in costs year over year.

Dubbed by workers compensation experts as a trend to watch, the new type of medication targets migraine-inducing calcitonin gene‐related peptides. The first drug — erenumab — hit the market in 2018 after receiving Food and Drug Administration approval, and several other drugs have followed, with most injectable-only. Since then, those managing injured worker claims say they’ve gradually seen more prescriptions among comp patients.

“In our arena it's typically related to some type of traumatic brain injury or some other trigger that's been accepted on the claim that has something to do with (migraines) or, there's brain damage or something that's causing it,” said Nikki Wilson, Omaha, Nebraska-based senior director of clinical pharmacy services at Enlyte.

“That's one of the big reasons it is rising, because these new drugs on the market work so well, and they're being recognized by the guidelines, as well as an option for first-line treatment” of migraines, she said.

Silvia Sacalis, Tampa, Florida-based vice president of clinical services for Healthesystems LLC, said the newer drugs have in some cases replaced other types of drugs that help treat migraines. She said the newer drugs have risen in popularity among doctors treating traumatic brain injuries in part due to effectiveness.

Another reason for the uptick is that migraines can be triggered by injuries or stress on the body, effectively connecting the prescription to the work injury, according to Ms. Wilson, who said it’s “up to the discretion of the carrier or who’s covering the comp injury if they're going to accept that or not.”

Dr. Marcos Iglesias, Hartford, Connecticut-based chief medical director at Travelers Cos. Inc., said it’s imperative that the drugs, which come at a higher cost than most pain-relieving nonsteroidal anti-inflammatory drugs or acetaminophen, are not used for headaches – an issue that has cropped up as the conditions can be similar but are starkly different.

Several medical organizations have noted some patient confusion over migraines — described as a debilitating neurological condition that can include such symptoms as nausea, vomiting, eye and neck pain, and muscle aches — as compared with such conditions as tension headaches. 

“It’s all about the appropriate use,” Dr. Iglesias said. “We need to make sure … they're being prescribed for migraines, not just for headaches. There's a lot of utilization review and education around those because (the drugs) can be expensive. If a claimant has a migraine as a result of a work injury, that may be the type of medication we use.”

Reema Hammoud, Southfield, Michigan-based assistant vice president of clinical pharmacy for Sedgwick Claims Management Services Inc., said the comp industry is also cautious as the drugs are relatively new.

“We don't have a lot of data on these drugs yet,” she said, noting they are based on newer medical research and come with “a risk of infection” and may also have some “cardiovascular effects.”

“We don't know the long-term side effects of these drugs,” Ms. Hammoud said.

Ms. Sacalis said some of the newer drugs may also worsen hypertension – a common comorbidity — and that the injectable medications can cause problems at the injection site.