- 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
OR
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 |
* Check the member's benefits; some agents may require prior authorization
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 |
rizatriptan (Maxalt, Maxalt MLT ) | One (5 or 10 mg) tablet PO at onset of migraine headache; | Maximum dose of 30 mg per 24 hours |
Drug | Dosing Regimen | Authorization Limit |
---|---|---|
Alsuma Injection | Migraines | 2 kits (4 doses) per month, 6 months |
Alsuma Injection | Cluster Headache One subcutaneous injection at onset; maximum of two injections in 24 hours separated by at least one hour | 6 months |
Imitrex Injection | Migraine One subcutaneous injection at onset; maximum of two injections in 24 hours 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 to dry, intact, non-irritated skin of upper arm or thigh; no more than two patches 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 |