A new study led by the Headache & Migraine Policy Forum and recently published in the journal Headache quantifies the extent to which insurance barriers continue to limit access to effective migraine treatments. The study found that widespread “Payer Blocking,” whereby health plans delay and deny coverage for prescribed migraine therapies, severely disrupts care as the resulting misalignment between clinical guidelines and payer practices not only undermine patient outcomes but also increases costs across the health system. The key findings include:
Across the more than 1,200 insurers studied, denial rates ranged from zero to nearly two thirds, and roughly one in five patients experienced repeated insurance barriers. These barriers often stem from requirements like prior authorization or step therapy.
When patients were denied the treatments their clinicians recommended, they were significantly more likely to end up in the emergency room or hospitalized. These denials were also associated with $624 to $3,016 in higher annual medical spending per patient, evidencing that shortterm drug cost savings often leads to longer term increases in health care expenditures.
Researchers found that payer blocking was more common among patients with lower income, lower educational attainment, and among Black and Hispanic patients. These inequities mirror broader challenges in navigating coverage requirements and accessing health care.
Claims Data Review
The analysis examined insurance claims to understand how frequently patients encounter denials for migraine medications, which patients are most affected, and how these barriers influence downstream medical use. The research reviewed data from more than 1,200 managed care organizations and reviewed claims for over 370,000 people treated for migraine between 2019 and 2021.
The American Headache Society now supports calcitonin gene–related peptide, or CGRP, targeting therapies as firstline options for prevention, yet many insurers still require patients to fail older therapies first. Because every CGRP therapy on the market is branded, prior authorization requirements, steptherapy mandates, and formulary restrictions play an outsized role in determining whether patients can access recommended care.
Bottom Line
The study concludes that payer blocking in migraine care is widespread, costly and out of step with current clinical guidelines. Reducing unnecessary insurance barriers would benefit patients, clinicians, insurers and the broader health care system. By “unblocking” effective treatments and making them more accessible to people living with chronic migraine, payers can help lower overall health care spending while improving patient outcomes, workforce productivity and quality of life.
