Navigating Effective Approaches to Migraine Treatment for the Underinsured

Despite the availability of new therapies, the vast majority of people with migraine headache receive inadequate treatment. A 2013 study by Lipton et al¹ proposed 3 steps to achieving minimally effective pharmacologic therapy for acute and chronic migraine, including

·consultation with a prescribing healthcare professional;

·diagnosis of migraine; and

·use of appropriate acute treatments.

In follow-up, the Chronic Migraine Epidemiology and Outcomes (CaMEO) study in 2016² reported that a stunning minority of people with chronic migraine, less than 5%, successfully navigated all 3 steps to achieve satisfactory migraine management. Poor or no health insurance coverage was an important predictor of whether a consultation for migraine would even be sought.^1,2

Factors Contributing to Nonoptimized Care

According to a 2018 review of challenges to migraine management, low socioeconomic status is a significant contributing factor to progression from episodic to chronic migraine, as well as outcomes and quality of life for patients with migraine.³ “Individuals who are underinsured or uninsured tend to have less access to care,” explained study coauthor,  Teshamae Monteith, MD, FAHS, chief of the Headache Division, Department of Neurology at the University of Miami, Miller School of Medicine, and a clinical neurologist at the University of Miami Hospital and Clinics-UHealth Tower in Miami, Florida in an interview with Neurology Advisor. “As a consequence, they may have untreated and more frequent migraine attacks, which in itself is a risk factor for progression to chronic migraine,” she said.

Dr Monteith noted that migraine in underinsured populations may contribute to downward social mobility. Frequent migraine is associated with both work loss and socioeconomic consequences, she noted, and conversely, low socioeconomic status is a risk factor for migraine. “Depression, anxiety, and insomnia, and poor quality of life are also special concerns for untreated migraine, especially those with higher rates of disability,” she added.

Risks to Undertreatment of Migraine

“Migraine is managed most commonly by primary care physicians and general neurologists, as headache specialists specifically are quite scarce,” Matthew Robbins, MD, a clinical neurologist at Weill Cornell Medicine and New York Presbyterian Hospital in New York City told Neurology Advisor. “Underserved populations may utilize the emergency department of hospitals for migraine disproportionately because of inadequate care, which in the long run is certainly more costly on our healthcare system. These encounters manage the acute crises, but are not able to focus on preventive treatment, contributing to an added risk of progression from low- or intermediate-frequency to full-blown chronic migraine,” Dr Robbins said, pointing out that “low socioeconomic status is also associated with this transition of episodic migraine progressing to chronic migraine.” The Lipton study reported an increased risk for new-onset chronic migraine was self-reported over the course of a year in a group of over 5000 patients with episodic migraine.¹

Dr Monteith pointed to troubling attempts at self-management that also contribute risks of developing a more chronic course of migraine. “Without adequate access to care, people who suffer from disabling migraine attacks may be more likely to treat with over-the-counter medications [OTCs]. When acute treatment occurs on more than 10 to 15 days per month, there may be a risk of migraine progression due to medication overuse of acute analgesics,” Dr Monteith said.

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.

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.

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.