Report Examines Migraine Drugs as a Potential Cost Driver in California Workers’ Comp

Migraine drugs represent a small percentage of prescriptions dispensed to injured workers in California, but they make up a larger share of workers’ compensation drug payments, a new report shows.

Fewer than 1% of all prescriptions dispensed to injured California workers in 2023 were migraine drugs. However, these drugs consumed 4.7% of workers’ comp drug payments, nearly an eight-times increase since 2018, according to a California Workers’ Compensation Institute study that links to the emergence of high-cost brand drugs not listed in the Medical Treatment Utilization Schedule (MTUS) Formulary.

Migraines, a neurological disorder characterized by severe headaches and often accompanied by nausea, dizziness, and sensitivity to light and sound, is not a common work injury, but it is common in the general population. Migraine diagnoses are based on a patient’s symptoms, personal and family history, and exposure to triggers.

In recent years the use of migraine drugs has increased as new pain relieving and preventive drugs have been approved and hit the market, according to the CWCI study. Migraine Drugs represented 0.7% of California workers’ comp prescriptions filled in 2023, up from 0.2% in 2018.

This growth, the ongoing evolution of the migraine drug market and the growing use of several high-cost brand-name drugs for which there are no generic equivalents, drove the migraine drugs’ share of the workers’ comp drug spend up from 0.6% in 2018 to 4.7% last year, according to CWCI.

The study uses data on more than 9.5 million California workers’ comp prescriptions filled between 2010 and 2023.

It found that the top two migraine drugs prescribed in 2023 were relatively inexpensive sumatriptan (such as Imitrex) and rizatriptan benzoate (Maxalt), but from 2018 through 2023, these drugs’ share of workers’ comp migraine drug prescriptions dropped from 75.6% to 52.3% while their share of the migraine drug spend fell from 38.0% to 5.5%.

Over the same period, the CWCI study identified six cost-driver migraine drugs approved by the FDA and introduced into the system, which are as not listed drugs in the MTUS Formulary:

• Aimovig Autoinjector (Erenumab-aooe) accounted for 23.4% of the California workers’ comp Migraine Drug spend and by 2021 it represented 8.8% of the Migraine Drug prescriptions. With new drugs coming online, by 2023 it fell to 5.7% of the migraine prescriptions, but with an average payment of $708 per prescription, Aimovig still consumed 6.7% of the migraine Drug spend.
• Ajovy (Fremanezumab-vfrm) by 2020 represented 3.5% of California workers’ comp migraine prescriptions but at an average of $617 per prescription it represented 8.6% of the Migraine Drug dollars. By 2023, Ajovy had grown to 4.6% of the migraine prescriptions and the average payment grew to $817, but with the introduction of higher-cost alternatives, its share of the migraine drug spend fell to 6.7%.
• Emgality (Galcanezumab-gnlm) by 2020 represented 4.3% of the migraine prescriptions and with reimbursements averaging $667 it consumed 11.5% of the migraine drug payments. As non-injectable options came on the market, Emgality’s share of the prescriptions fell to 2.6% by 2023, but payments averaged $649 so it still represented 2.8% of the migraine drug spend.
• Ubrelvy (Ubrogepant) in December 2019 became the first oral gepant approved for acute migraine pain and other symptoms, but it was not indicated as a preventive treatment. By 2021 Ubrelvy accounted for 4.4% of workers’ comp Migraine prescriptions, but with an average payment of $1,426 it represented 17.2% of the migraine drug payments. Ubrelvy’s share of Migraine prescriptions climbed to 7.0% last year, though the average paid has fluctuated along with the average number of tablets dispensed, so in 2023, the average payment was $1,507 while its share of the migraine dollars was 17.4%.
• Nurtec ODT (Rimegepant Sulfate) in 2021 accounted for 3.7% of workers’ comp migraine prescriptions and with payments averaging $1,277, it represented 12.8% of the Migraine Drug spend. Nurtec’s share of the prescriptions jumped to 9.4% in 2022, then to 15.0% in 2023 while average payments rose steadily to $1,675 in 2023, driving its share of the migraine dollars up to 41.6%, making it the fastest growing migraine drug in California workers’ comp, both in terms of utilization and payments.
• Qulipta (Atogepant) workers’ comp prescriptions first appeared in significant volume in 2023. By the end of 2023 it accounted for 3.1% of the migraine drug prescriptions dispensed last year, and with an average reimbursement of $1,106 per prescription, it consumed 5.7 percent of the 2023 migraine drug spend. The emergence of Qulipta in workers’ comp coincided with the declines in the three injectable monoclonal antibodies (Aimovig, Ajovy, and Emgality) which together fell from 16.2% of the migraine drug prescriptions in 2022 to 12.9% in 2023, while their share of the migraine drug spend fell from 24.4% to 16.2%, signaling an ongoing shift within this drug group.

Migraine drugs did not rank among the top 10 drug groups in California workers’ compensation a decade ago, but now rank sixth in terms of total payments, with aggregate expenditures approaching those of opioids and surpassing those of antidepressants and musculoskeletal drugs, according to the CWCI.

CWCI published more details and analyses on these drugs in a Spotlight Report, Trends in the Utilization and Reimbursement of Migraine Drugs in California Workers’ Compensation. Institute members and subscribers can log on the CWCI website and access the report under the Research tab, others can purchase it from CWCI’s online store.