Although treatable, migraine often goes untreated, and even undiagnosed, as a result of multiple barriers to appropriate care.1-3 According to results of a large-scale review of underserved populations with headache, lack of sufficient insurance is one of the major factors affecting access to care among people of low socioeconomic status, and is associated with worse migraine-related quality of life and outcomes.1,2 “Our current insurance system may be partly helpful for migraine patients who have excellent insurance coverage, but does not adequately serve underinsured patients or patients with no insurance,” study coauthor Teshamae Montieth, MD, FAHS, FAAN, told Neurology Advisor.
Dr Montieth, who is chief of the Headache Division and fellowship program director at the University of Miami Miller School of Medicine in Florida, explained that, “In addition, patients with commercial coverage are subject to step programs and restrictions due to cost containment, which often limits a physician’s ability to provide the most effective treatment plan.” She pointed to the requirements to use oral preventive treatments with less or no evidence before initiating onabotulinumtoxinA therapy for chronic migraine, as an example. “More recently, restrictions to the combination use of onabotulinumtoxinA therapy and calcitonin gene-related peptide monoclonal antibodies has also been imposed and has been harmful for patients who have to stop treatments,” she added.
Failing to Seek Care
“Not having health insurance is a barrier to receiving guideline appropriate care for people with both episodic and chronic migraine, explained Dawn Buse, PhD, a clinical professor in the Department of Neurology and clinical psychologist at Albert Einstein College of Medicine of Yeshiva University. But many patients without insurance never seek a medical consult for migraines.
“If we think of the path to optimized care as consisting of several contingent steps, it has been established that lack of health insurance is a barrier to the first step: seeking medical care for migraine, which is a precursor to receiving a diagnosis, which is typically a precursor to receiving guideline-based therapies for migraine, which may include acute and pharmacologic and nonpharmacologic preventive therapies,” said Dr Buse, who is coauthor on 2 of the largest epidemiologic studies of migraine, the American Migraine Prevalence and Prevention (AMPP) Study and the Chronic Migraine Epidemiology and Outcomes (CaMEO) Study.3,4
Data from the AMPP study4 of episodic migraine showed that the strongest predictors of accessing medical care for migraine were having sufficient health insurance and a high symptom severity score, whereas the CaMEO study3 showed that having health insurance was a significant factor in seeking medical treatment, along with age, higher body mass index, migraine-related disability, and severity of symptoms.
Influence of Type of Provider
When underinsured patients do seek care, it is often through visits to either a primary care provider or a hospital emergency department (ED), which strongly influences the treatment plan.3