- Acute treatment of migraine attacks, with or without aura in adults
- Alsuma, Imitrex Injection, Sumavel DosePro: Acute treatment of cluster headache in adults
AND
AND
- Failure or clinically significant adverse effects to TWO formulary 5HT1-agonist migraine medications (e.g., AmergeR, Axert, ImitrexR oral) at maximum tolerable doses
OR
- Patient cannot take oral agents due to migraine associated nausea
AND
AND
Preventative Therapies for Migraine | ||
Class | Commonly Used Examples | Dose/Limit/Maximum Dose |
Anticonvulsants* | divalproex (DepakoteR), topiramate (TopamaxR) | Varies according to the agent used |
Beta blockers | propranolol (InderalR), metoprolol (LopressorR), atenolol (TenorminR) | Varies according to the agent used |
Antidepressants/ Tricyclic antidepressants | amitriptyline (ElavilR), venlafaxine (EffexorR) | Varies according to the agent used |
Non steroidal anti-inflammatory drugs (NSAIDs) | Fenoprofen (NalfonR), ibuprofen (MotrinR), ketoprofen (OrudisR), naproxen (NaprosynR) | Varies according to the agent used |
Drug | Dosing Regimen | Dose Limit/ Maximum Dose |
---|---|---|
naratriptan (Amerge) | One tablet (1 or 2.5 mg) PO at onset; | Maximum dose of 5 mg per 24 hours |
sumatriptan (Imitrex nasal spray) | One spray (5 - 20 mg) at onset into one nostril; | Maximum dose of 40 mg per 24 hours |
sumatriptan (Imitrex tablets) | One tablet (25 -100 mg) at onset; | Maximum dose of 200 mg per 24 hours |
almotriptan (Axert) | One tablet (6.25 -12.5 mg) PO at onset, can be repeated after 2 hours | Maximum dose of 25 mg per 24 hours |
Drug | Dosing Regimen | Authorization Limit |
---|---|---|
Alsuma Injection | Migraine: | 2 kits (4 doses) per month, 6 months |
Alsuma Injection | Cluster Headache: One 6mg subcutaneous injection at onset; maximum of two injections (12 mg) in 24 hours separated by at least one hour | 6 months |
Imitrex Injection | Migraine: One subcutaneous injection of 1 to 6 mg at onset; the maximum cumulative dose in 24 hours is 12 mg and doses should be separated by at least one hour | 2 kits (4 doses) per month, 6 months |
Imitrex Injection | Cluster Headache: | 6 months |
Sumavel DosePro | Migraine: | 1 kit (6 doses) per month, 6 months |
Sumavel DosePro | Cluster Headache: | 6 months |
Zecuity | Migraine: Apply one patch (6.5 mg) to dry, intact, non-irritated skin of upper arm or thigh; no more than two patches (13 mg) should be used in any 24 hour period; second patch should be used no sooner than 2 hours after the first patch was applied | 4 patches per month, 6 months |
Onzetra Xsail | Migraine: | 1 kit (8 doses) per month, 6 months |
Zembrace | Migrane: | 2 cartons (8 doses) per month, 6 months |