HCRU Burden of Chronic vs Episodic Migraine and Effect of Early vs Late Nonoral Triptan Use

Migraine is an extremely common condition, affecting more than 15% of Americans aged 18 years or older in the United States—a statistic that has remained consistent for more than 20 years—prompting payers to constantly review the burden on patients and resource utilization to provide the best patient care and coverage.

HCRU analyses for managed care consideration reaffirmed previous findings that chronic migraine is associated with increased disease and economic burden compared with episodic migraine. Additionally, early use of nonoral triptans was linked with decreased burden when compared to late use. This data supports the concept that nonoral migraine nasal sprays and injections have the potential to lower overall health care costs.

These findings were collected via a longitudinal pharmacy claims data analysis using MarketScan Commercial Claims and Encounters, and MarketScan Medicare Supplemental and Coordination of Benefits (COB) databases from July 2011 through December 2017, and examined medication utilization, health care utilization, and costs for episodic vs chronic migraine; and early vs late use of nonoral triptans (intranasal and injectable triptans).

Patient data included in the analysis met the following criteria:

•  ≥1 primary inpatient or ≥2 non-diagnostic outpatient claims with a diagnosis for migraine using with ICD-9-CM 346.x; ICD-10-CM G43.x codes from July 1, 2011 through December 31, 2017
• ≥18 years of age at index (defined as the first migraine claim)
• ≥6 months continuous enrollment and pharmacy benefits before index
• ≥12 months of continuous enrollment and pharmacy benefits after index
• No evidence of migraine diagnoses during the pre-index period
• No evidence of triptan use during the pre-index period

The final cohort for the episodic vs chronic migraine analysis included 470,103 patients; 406,528 with episodic migraine and 63,575 with chronic migraine. According to the analysis, “chronification,” or the decision to commit a patient to a chronic migraine diagnosis, resulted in increased disease and economic burden for patients and payers. In fact, the chronic migraine cohort used more medications than those with episodic migraine and incurred greater mean annual prescription fills (30-day supply) of acute (9.7 vs 5.8) and preventive (8.5 vs 4.8) migraine medications, a 40.2% and 43.5% difference, respectively.

Acute migraine medications included: acetaminophen (prescription only), barbiturates, nonsteroidal anti-inflammatory (prescription only), ergot alkaloids, opioids, and triptans (oral, intranasal, injectable). Preventive medications included: anticonvulsants, antihypertensives, antidepressants, and botulinum toxins. Calcitonin gene-related peptide (CGRP) modulators, gepants, and ditans were not approved at the time of analysis.

Mean annual costs measured were $219 and $140 for emergency department visits; $448 and $31 for outpatient medical claims for acute or preventive medications; and $1406 and $585 for outpatient prescription costs, for chronic and episodic migraine respectively.

Patients with episodic migraine also had fewer annual neurologist office visits, reduced outpatient hospital costs, and lower outpatient prescription costs.

In a second analysis, it was noted that later use of nonoral tripans, like nasal sprays and injections, increased costs suggesting that payers should consider the impact of limited access to these therapy options.

For this part of the analysis, of the total 470,103 patients with migraine, 196,833 reported ≥1 fills for a triptan. Of this subgroup group, 17,652 nonoral triptan users were identified, with 8,573 being “early” users (having an injectable or intranasal fill in the 6 months following diagnosis), and 9,079 being “late” users (having an injectable or intranasal fill more than 6 months after diagnosis).

Overall, this subanalysis demonstrated early nonoral triptan users experienced reduced inpatient hospitalization (4% vs 3%), reduced emergency department visits (36% vs 27.4%), and lower mean per patient per year outpatient prescriptions (16.6% vs 15.9%).

Early users incurred an average $725 less in total annual migraine-specific health costs overall.

These analyses suggest reducing the number of patients with chronic migraine could help control costs and utilization burden. Findings also suggest the early use of nonoral triptans, like injectables and nasal sprays, may be beneficial to patient outcomes and overall health care costs.

References:

1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control Acute Migraine. Updated May 11, 2020. Accessed January 3, 2022. https://www.cdc.gov/acute-pain/migraine/
2. Upsher-Smith. Final Report: Treatment Patterns and Progression in Migraine, December 9, 2020, IBM Watson Health. Data on file, 2022.