Migraine in the managed care environment

Migraine headache remains a major clinical problem in the managed care environment, incurring a heavy toll in terms of treatment costs, patient disability, and patient quality of life. Abortive treatment with triptans has become the standard of care in patients with acute episodic migraine. However, there is no such consensus about the optimal approach to prophylaxis in patients with frequent or intractable migraine. The agents currently approved in this role are not always effective and may cause systemic side effects. One potential alternative to currently approved treatments may be botulinum toxin. When injected into carefully pinpointed pericranial locations at 3-month intervals, botulinum toxin may offer effective prophylaxis with minimal side effects. However, the evidence available to date has been inconsistent, with benefit seen in some reports but not in others. Consequently, managed care policymakers have been cautious about approval of coverage for this treatment. Specific criteria for the use of botulinum toxin vary among different plans. At present, many plans do not approve coverage for this agent for the treatment of migraine; other plans do allow coverage as needed for patients in whom conventional approaches have been ineffective or intolerable, but not as a first-line approach to prophylaxis.