What Payers Should Know About Managing Chronic vs Episodic Migraine Costs

Edmund Pezalla, MD, MPH, chief executive officer, Enlightenment Bioconsult, LLC, reviews the costs associated with chronic vs episodic migraine and what payers should keep top of mind when managing these patients.

Read the full transcript:

Welcome back to "Pop Health Perspectives," a conversation with the Population Health Learning Network, where we combine expert commentary and exclusive insight into key issues in population health management and more.

In this episode, Dr Ed Pezalla provides an overview of what payers should know about chronic vs episodic migraine.

I'm Dr Edmund Pezalla. I am a payer strategy and market access consultant. I have my own firm in consulting, Enlightenment Bioconsult, LLC. I have been the head of clinical services for a large national [pharmacy benefit manager], and most recently was vice president for pharmaceutical policy and strategy at Aetna—responsible for drug evaluations, pharmacoeconomics, and related internal activities; and externally, public policy related to pharmaceuticals and other things related to the US Food & Drug Administration. I now work full time as a consultant.

Thanks, Ed. Jumping right into the questions, can you compare the disease burden between chronic migraine versus episodic migraine?

Well, it is a little bit apples and oranges here. If we look at the burden of migraine overall, somewhere between 11 and 25 million Americans have migraine. That translates to about 12% of the population, but chronic migraine is probably about 2% of the population, leaving about 10% or 5 times as many who have episodic migraines. Patients with chronic migraine have a lot more problems.

They experience much more difficulty with school, with work, and with other daily activities. The burden on those individual patients is much higher, but the burden on society is even higher with episodic migraine because of the larger number of patients, and because it is difficult to predict which of those patients is going to have a problem with migraine on any one day.

What is the cost burden associated with migraine?

It was estimated in 2019 to be $19.3 billion. It has probably gone up some more since then due to inflation and wage inflation, and that is almost all indirect costs reported there. Direct costs—a little harder to come by—are probably in the billions, probably $1.5 to $2 billion. The reason why direct costs are less expensive is because they are mostly the medication treatment.

Most patients with migraines, many do end up in the emergency department, but they rarely end up being admitted. They don't get expensive procedures and things like that. The burden on the cost is really the indirect cost that falls onto the patient and their family.

Under what circumstances are nonoral triptans most effective?

It is difficult to predict the effectiveness of the triptans. It is very likely that patients who have episodic migraine, who have figured out how to use the triptans according to the package, so adherence in being able to inhale or to inject, making sure that that happens correctly. Otherwise, very difficult to predict which patients are going to get better using those, but once a patient does respond to it, then it seems you can establish that those are probably the responder patients.

Compared to late nonoral triptan use, how does early nonoral triptan use impact downstream costs?

Well, if patients are using it earlier, then they are more likely to prevent a full-blown migraine. This will have some impact on their ability to return to work or their activities, and so the indirect costs—the cost to them—will be less but it also means that these patients may be more successful in treatment, because they are catching it early and they are able to, essentially, abort the attack.

That means that they are less likely to be seeking other therapies later on, whether they are the therapies for prevention or treatment of chronic migraine, or episodic migraine. Since the newer drugs are very effective, like the CGRP drugs and there's a couple of different kinds are very effective, but they're also much more expensive than the standby drugs—the triptans.

Given all these data, can you comment on the relevance to payers?

Payers continue to have step edits or prior authorizations on some of the new drugs and so they feel that if patients are using triptans, if patients are using some of the older standby medications for prevention, that even though it's a small number, maybe only 15% of patients who really get full relief with those sorts of treatments, that it is still worth it in terms of preventing more use of the more expensive drugs.

This is often a strategy that is used by payers, because there is no really good way to sort patients into who will respond to other therapies, and which patients are going to get better on antiepileptic or a beta-blocker or something else. Part of the problem too is, even patients who do respond well to triptans, there is a monthly limit on triptans, which is in their package label, so, eventually, we need to be able to do a better job of sorting out which patients should go more directly to the older medications and like triptans, and which patients should go more directly to the newer CGRP-related medications.

Excellent, thank you, Ed, and is there anything else you wanted to add today?

I would like to say that we really do need to examine why we have patients go through triptans and other treatments first, oftentimes, they do anyway, because of the cost to the patient. I think we should examine how we manage the CGRP types of medications, and whether or not we can develop a better set of criteria for their use, so that patients can get to it more quickly.

Like many other pain areas, the more successful you are early on in treating the pain, the fewer medications overall the patients may be using, because you are interrupting learning in the neuro system, in terms of being able to transmit pain, and if there are fewer pain signals, there is less transmission and less learning. Essentially, if you have chronic pain, then the pathway for transmitting that pain becomes more efficient, and that is really what we want to avoid here.

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