Opportunities for Pharmacists to Optimize Migraine Prophylactic Treatment in ACOs

Pharmacists can provide education on migraine prophylaxis for better outcomes in the primary care setting under an accountable care organization (ACO), according to new research.

Tiffany Zeng, 2021 PharmD candidate at the University of Rhode Island, presented a poster on the topic at the American Society of Health-System Pharmacists 2020 Midyear Clinical Meeting and Exhibition, which was held virtually December 6-10, 2020.¹

“Pharmacists play an important role in providing provider recommendations when migraine symptoms are not well controlled,” Zeng said during the presentation. “Opportunities may exist within the ACO to provide education on migraine prophylaxis or to enhance pharmacy services to achieve better outcomes.”

The research team reviewed migraine drug scripts filled from January 1, 2020 through March 31, 2020 for ACO ambulatory care via Blue Cross Blue Shield’s Integra ACO in Rhode Island.

Out of 226 patients, 67% were currently prescribed prophylactic medications and 33% were not taking treatments.

Medications included: erenumab-aooe (Aimovig), galcanezumab-gnlm (Emgality), fremanezumab-vfrm (Ajovy), propranolol (Inderal, InnoPran XL), amitriptyline (Elavil, Endep, Vanatrip), divalproex (Depakote), verapamil (Verelan), and other drugs listed in the American Headache Society guidelines for preventative care.

Forty-seven percent of patients were considered symptomatically uncontrolled on prophylactic treatment. Within the patient cohort that was symptomatically uncontrolled,

66% were on a 1-drug regimen, 25.35% were on a 2-drug regimen, 8.45% were on a 3-drug regimen.

Of those not taking preventative medications, 31% were previously prescribed them but the treatments had since been discontinued and not replaced with an alternative.

“Finding a preventative regimen for migraines may be difficult,” Zeng told Drug Topics®. “Most of the medications that have data showing efficacy are drugs that are not indicated or designed to prevent migraines, except for the [calcitonin gene-related peptide (CGRP)]-inhibitors.”

However, CGRP inhibitors are not considered first-line treatment and, due to insurance coverage, patients may need to trial a number of medications before their insurance provider will cover a CGRP inhibitor, Zeng noted. “Therefore, patients are generally started out on other medications such as topiramate, divalproex, or amitriptyline which can either be non-efficacious for the patient or come with adverse effects that are intolerable for the patient.”

Some of the other reasons why medication alternatives were not used could be the lack of follow-up or the lack of knowledge about other medications available, “as these medications aren't FDA indicated for prophylaxis,” Zeng said.

Pharmacists can offer provider education on drug selection and the impact of acute medication overuse, Zeng said, and they play an important role in providing provider recommendations when migraine symptoms are not well controlled.

“Pharmacists have shown their role in the primary care setting in many ways. Under this ACO, I have seen the pharmacists help manage complex patients with uncontrolled diabetes, [chronic obstructive pulmonary disease], asthma, hypertension, or hyperlipidemia,” Zeng said.

“I believe that with the number of patients that were considered uncontrolled in my study, the pharmacists in this group could provide education or reinforce what providers may already know,” she added.

Reference

1. Zeng T, Gentili M, Ranucci S, Gianfrancesco A, Seasholtz M. Identifying opportunities for provider education to optimize migraine prophylactic treatment in the primary care setting under an accountable care organization. Presented at: ASHP Midyear 2020 Clinical Meeting and Exhibition; December 6-10, 2020. Accessed January 13, 2020.