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“Patients without insurance may seek care in the ED and urgent care clinic (UCC) settings, or in community clinics including Planned Parenthood, where they can be prescribed therapies,” Dr Buse observed, noting that treatment in these settings often had less-optimal outcomes.
“Unfortunately, as we saw in the MAST Study,5 people who sought care for migraine in the ED and [urgent care clinic] settings were more likely to receive an opioid prescription than if they sought care for migraine in a neurologist or primary care setting. There is also unlikely to be follow-up visits with that healthcare provider to discuss revising and optimizing treatment plans and creating tailored multidisciplinary plans,” Dr Buse said.
“Patients who seek care in ED and urgent care clinic settings are unlikely to be prescribed or recommended nonpharmacologic treatment options such as behavioral therapies or neurostimulators, and may also be unlikely to be prescribed preventive pharmacologic treatments due to lack of time for assessment and education, as well as lack of follow-up care,” she said.
Reduced Therapeutic Options
Choice of therapy is also frequently constricted by insurance providers. “Access to triptans, mainstay therapies for acute migraine, may be limited despite important differences in pharmacology, delivery, and side effect profiles,” Dr Montieth said.
A 2017 study by Minen et al6 found that because of the high cost of the medications, uninsured patients were 45% less likely to receive a prescription for triptans compared with patients with private insurance, despite being the most effective abortive therapies for migraine. Step therapy was required by 40% of 100 common plans studied.6
The same was shown in the AMPP study, Dr Buse reported. “We found that rates of triptan use and other migraine-specific acute therapies were lower among uninsured people with migraine following lower rates of medical consultation for migraine among this group, because, as a prescription is required for a triptan in the United States, medical consultation is a necessary precursor.” She pointed out that since many triptans are now generic, “if someone obtains a prescription, is it likely that the medication itself may now be affordable for them.”
Alternative Therapies That May Be Effective
Dr Montieth suggested that in the absence of adequate healthcare insurance coverage, there are some therapies that can help patients with migraine. “Amitriptyline and propranolol are relatively cheap,” she said, noting that, “nonspecific treatments such as nonsteriodal anti-inflammatories are also inexpensive, although most patients that present to treatment of migraine may benefit from migraine-specific treatments such as triptans.” She added that supplements such as CoQ10, butterbur (Petadolex), magnesium, feverfew, melatonin, and riboflavin (vitamin B2) are supported by the evidence. “The use of acupuncture, cognitive behavioral therapy, aerobic activity, and biofeedback may also be effective for migraine prevention,” Dr Montieth said.
References
1. Charleston L 4th, Royce J, Montieth TS, et al. Migraine care challenges and strategies in US uninsured and underinsured adults: a narrative review, part 1. Headache. 2018;58(4):506-511.
2. Charleston L 4th, Royce J, Montieth TS, et al; Underserved Populations in Headache Medicine Special Interest Section of the American Headache Society. Migraine care challenges and strategies in US uninsured and underinsured adults: a narrative review, part 2. Headache. 2018;58(5):633-647.
3. 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(5):821-834.
4. 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(1):81-92.
5. Schwedt TJ, Alam A, Reed ML, et al. Factors associated with acute medication overuse in people with migraine: results from the 2017 migraine in America symptoms and treatment (MAST) study. J Headache Pain. 2018;19(1):38.
6. Minen MT, Lindberg K, Langford A, Loder E. Variation in prescription drug coverage for triptans: analysis of insurance formularies. Headache. 2017;57(8):1243-1251.
