The box of nine Amerge that I just picked up from the pharmacy has gone missing. My anger and anxiety about that fact are far greater than might seem reasonable, but I’m betting other people with migraine know exactly why I’m reacting this way. It’s not just the cost that has me worried, it’s that I have to wait another month to get a new prescription filled. Thanks to triptan rationing by cost, insurance company limits, and doctors’ limits, these pills are precious commodities to people with frequent migraine attacks.
A study presented at the American Headache Society conference in June found that for 43% of attacks, patients skip taking triptans.1 The study didn't look at why this happened. Coincidentally, I'd already written this article exploring the issue from a patient's perspective. Here’s a look at how triptans are rationed and why and the reason this is such a problem for those of us who have frequent attacks.
High cost of triptans. In one study, 37% of patients said the cost of the medication prevented them from even filling their triptan prescriptions.2 Having health insurance prescription coverage doesn’t always lower the cost much because triptans usually have high co-pays. My eyes popped when I checked prices using a discount drug card recently. These prices are less than the cash rate without any insurance or discount card.
- Imitrex (generic): $1.67 per pill
- Amerge (generic): $5.45 per pill
- Zomig (generic): $12.83 per pill
- Relpax (brand): $37.61 per pill
- Frova (brand): $45.64 per pill
If price were the only factor, everyone would use sumatriptan (generic Imitrex). However, not every patient is helped by every triptan. Some try every one of the seven different triptans and only have success with one. Different drugs also have different side effects, and certain drugs are intolerable for some people. Additionally, people with sulfa allergies are advised to avoid sumatriptan.
Insurance companies limit the number of triptans they’ll pay for. My limit is nine triptans, which is actually high considering that many insurance companies have a ceiling of between three and six triptans a month. This is true for both name-brand and generic triptans. The argument is that most people don’t need more than that. It’s true that six triptans a month is plenty of medication for many migraineurs, but not all of us. The study looking at cost and triptan use found that 42% of patients do not get as much medication as they need each month because of insurance coverage limits.2
Doctors limit the number of triptans they’ll prescribe. Medication overuse (rebound) headache can put a person in a terrible cycle of migraine attacks or headaches that they’re unable to break. To avoid this risk, many doctors prescribe no more than 10 triptans a month. Depending on the patient and their treatment history, doctors sometimes prescribe a higher amount. Very occasionally, triptans are even used as daily preventives.
Triptan limits lead to a conundrum in migraine treatment. We’re told that if we don’t treat migraine attacks aggressively, our attack frequency is likely to increase. Yet, we can’t be aggressive in our treatment if we don’t have enough triptans to last a full month. All this means that the people whose lives are most affected by migraine have the least access to the medications that provide relief.
When those nine triptans went missing, I didn’t lose nine pills—I lost nine migraine-free days.
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