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Triptan Rationing

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.

 

This article represents the opinions, thoughts, and experiences of the author; none of this content has been paid for by any advertiser. The Migraine.com team does not recommend or endorse any products or treatments discussed herein. Learn more about how we maintain editorial integrity here.

  1. American Headache Society 57th Annual Scientific Meeting:Longitudinal Real and Near-Time Assessment of Acute Medication Adherence During Migraine Attacks (Abstract PF15). Presented June 19, 2015.
  2. Insurance Limitations and Cost of Triptans Negatively Influence Use Patterns, Quality of Life. Medscape. Jun 18, 2007.

Comments

  • maria.deleon moderator
    2 years ago

    Kerrie, thank you for covering this crucial topic. insurances have made the cost of drugs a true mockery in which only people that suffer are the patients and doctors have increased grief. the total number of pills are not limited by the physicians rather imposed by the particular individuals insurances..at times with preauthorization doctors can write for maximum of 24 tabs – which i never understood rational because have to break one pack and remove 3 tabs – any way – ask your insurance and doctor to see if you can get more than 9 tablets. another option which i have resorted to at times for my patients and myself is purchasing these medications in canada for lesser price except that you have top pay out of pocket.thank you. maria de leon/ moderator/ patient advocate

  • Candy
    4 years ago

    I have done the same so many times! I have chronic migraine, so at least 15 times a month, and I too am allowed 9 pills. There have been many times that I have skipped my pill and just gone to bed in hopes that I would be able to sleep in away. I certainly know better, and that usually results in me having to use two pills to finally get rid of the migraine. I really do not understand why some rep in an insurance company somewhere gets to decide what is best for our health over what our doctors think.

  • David
    4 years ago

    I discovered imitrex almost 20 years ago. It was a Godsend, literally gave me my life back and allowed me to keep my job as a computer programmer/analyst. For about 10 years my family doctor prescribed all the imitrex and other triptans I needed, then suddenly informed me that he would not prescribe any triptan for me at all. He instructed me to visit a neurologist who offered me a prescription for only 9 tablets. She gave me the speech I have heard many times now from many doctors. “You are ruining your health by taking triptans, blah, blah, blah…” Then she promptly offered me a prescription for 9 100-mg tablets. Since I was using the 50-mg at that time I would have 18 doses instead of 9. Suddenly it was ok to endanger my health with 18 doses. WOW! What a travesty, what a sad commentary on our medical system. I wanted to say: ‘Do the insurance companies control everything you do?’ But I didn’t say anything. I accepted the prescription with 6 refills, happy to have what I needed but appalled at the reason for the whole scenario.

    Could it be that she simply had to find a way around the insurance company to get the pressure off her? hmmm

    Later I changed family doctors. I told the new doctor I have migraines every day at times. She scribbled a prescription for 30 tablets with 6 refills. Worked fine for a few years, then one day she refused. I would need to see a neurologist. It’s getting boring now. Similar things have happened a couple more times. I have seen a headache specialist who would give twice the number of pills for some reason.

    I have been through antidepressants, seizure medicine, beta blockers, injections in my neck, and too much hydrocodone.

    I know that what I need is about 20 sumatriptan talets each month. Currently I cannot find a doctor who will see that.

  • lerickson82
    4 years ago

    I agree that this is a problem. Not sure if anyone is like me, but the more I am limited in pills, the more that I NEED the pills. I know it’s partly psychological for me. If I’m starting to get low, I actually start to worry and get stressed. The more THAT happens, the more migraines I get, and so it goes. I DO understand about the Medication Overuse or “rebound headache” because I’ve been there too, but until you have a working “detox” plan, and a working alternative for afterwards in place, all you can do is take something everyday to survive. So far I’ve been ok on 9 pills a month, but I also supplement it with Aleve, Orphenadrine, botox, physical therapy and chiropractic. I was taking Relpax before I switched to Treximet and my insurance was only giving me 4 pills at a time, which still equaled 8 in a month, but it caused a lot of stress for me. Like, what if I have a really bad two weeks?

  • Katyb
    4 years ago

    Robertcan, I agree with your comment below 1,000%! I take Imitrex way more than I probably should because I MUST. I have done the whole detox thing many times and find that I last 4 days tops with no migraine at all after detoxing off all meds and that includes OTC meds except for plain old Tylenol. That’s what they do at inpatient migraine clinics. Then, all it takes is a simple “something” coming on i.e. cold, bug, etc. or a stressful day and I’m trying like hell to use OTC meds only – meanwhile, they are ripping my stomach apart – and, finally, reach for my savior, Imitrex. I also take Fioricet and about 50% of the time that works to “get” it in time before I have to take Imitrex. That, too, is used sparingly because of rebounds.

    My situation is a bit different than some as the insurance can limit me all they want and I still get probably 25/month. How, you ask? Well, my pharmacy gives me what’s called a discount card (as if I have no insurance) and I use that. So, for 10 generic pills, I pay $45.00. It’s not going to break the bank for me and they’re worth it. I don’t care if they’re triple that: I NEED them. I don’t drink or smoke and eat a healthy diet. I’m a 62 yr. old female who gets 9 hrs. of sleep, exercises and has a nice life with great spouse and 2 incredible sons. Why I get these is beyond me. I will NOT go the “preventative” route i.e. Topamax, etc. because I am not messing with these anti-epileptic drugs. I’ve seen too many women go into la-la land with those, and eventually, get off them.
    Currently, I’m going through a bad sore throat and cough, and naturally, with that, I get a migraine constantly! UGH! I get so disgusted………………. I know you all know where I’m coming from. I’m trying to stick to plain aspirin and Tylenol, but in the next 24 hrs. I’ll get so disgusted, that I’ll be reaching for the Imitrex.
    I do have to ration, though, like everyone else here. If I travel, I have to pack alot extra because you never know about climate, sickness, stress from traveling, etc. So, then, I have to plan a month in advance for that! Again: UGH! I wish we could all live without this curse. It’s truly a disability with some. I don’t have the disabling kind all that much in years of suffering (since I’m 18), but I have loads of empathy for those that have the disabling kind. It’s good to have found this forum. BTW, I don’t know why I have this coded name as my commenting name, but my real name is Kathie.

  • Jill M.
    4 years ago

    Kathie,

    You can go into your profile, choose edit and change your display name if you wish. 🙂

    Jill

  • RobertCan
    4 years ago

    I’m a chronic migraineur taking Imitrex and botox. Triptan rationing creates an impossible cycle of pain. It forces patients to delay treatment until its too late. Then we end up chasing pain levels which sometimes requires us to take two triptans in a 24 hr period, raising our stress level because now we have even fewer pills to treat our pain. A vicious cycle we’re forced to create by insurance.

  • 23r1c5h
    4 years ago

    I have only recently begun to take sumatriptans for my complex migraines (I’m two months into this treatment) and already I am rationing because of the price. The doctor prescribed me 15 100mg tablets that I break in half but it’s not even close to what I really need to gain any relief – her original prescription would have cost me $70/month and I am disabled, currently fighting for my disability, have zero cash and relying on others to get my meds.

    Ninety percent of my migraines are triggered by the weather and if we have a bad month of storms or excessive high pressure, I am down for days and days at a time. I am relying heavily on my Promethazine to “treat” the migraine when it’s really for my nausea and I am rationed to a mere 10 pills a month with that.

    To me, this is absolutely disgusting that we cannot get the meds we need to survive and when we do, we have to pick and choose which migraine to treat. I’ve been lucky so far in being able to predict when a migraine is going critical and I take what I am prescribed but luck only goes so far.

  • Flapharder
    4 years ago

    For once in my life I can say I am VERY happy to be living in “third world” South Africa. There is no limit to triptans here at all. In fact it is VERY common for migraine sufferers here to take triptans as a daily preventative, as part of the treatment.

    By the way, I have heard that SAMe (health product), is really good with preventing, or aborting oncoming migraine attacks. Has anybody tried this product with any amount of success?

  • MigraineSavvy
    4 years ago

    I take 1600 mgs a day of SAM-e and it does nothing for my migraine attacks. But I will not be without it as it works a treat for the depression.

  • ktron
    4 years ago

    Relpax — what a wonder drug for me! It actually floats the migraine away without making me feel like I’ve been beaten with a baseball bat for 20 minutes like all the other triptans, and trust me, I’ve tried them all, including injectables. My neurologist prescribes me 12 a month, so yay, she understands that I really do need something that will interrupt my 15 or so migraines a month. My insurance company, on the other hand, thinks 6 pills a month is a gracious plenty. So every month is spent bargaining with the pain. How bad will this one become? Is this really a migraine, or is it “just” a headache? I don’t have triggers, my head just blows up without warning, so it’s not like I can see them coming. Not only do I spend more days in pain than I should, but when I do take the pill, often it’s too far into the migraine to work as it should with one pill and I wind up having to take two. I’ve been doing this dance for a year now. Finally, as I had hoped, the neuro decided I was a good candidate for Botox. It seems to be working, although I went through what must have been a completely painless migraine last week that knocked me down for two days — until I brought Relpax into the picture. Amazing. No pain, but every other symptom in full force, until the Relpax came onto the scene.

    Anyway, that finally got me mad enough to call the insurance company — mainly because that experience took me down to 1 Relpax, and 10 days to my refill date. To my horror and delight, I found that all my physician had to do was call a preauthorization number, and I could get 12 pills. That’s it.

    So I have spent a year in useless, timewasting, mindblowing agony, shooting craps with pills and pain, and all it took was a couple of phone calls to end it. Of course the insurance company was not in a hurry to advertise this, it’s going to cost them money. The human cost, though…the cost to my employer…I never missed a day’s work, but I have to say I wasn’t as good a worker as I could have been.

    Shame on them. It’s the 21st century, for heaven’s sake. We are making people grovel to get what they need to function, and allowing pain to dominate too many lives. OK, I understand that there are issues with both addiction (not to Relpax, but to other pain meds) and illegal diversion to the street (certainly not to Relpax, “hey buddy, wanna buy some Triptans?”); but making this sort of policy with the goal of protecting society from itself backfires spectacularly every day. I personally know a cancer patient denied both pain and nausea drugs because they were potentially habit forming…two weeks before his death, hastened, I am convinced, by the debilitating effects of the pain. And was this particular decision about the war on drugs, or was it pure $$ and nonsense?

  • Robbie
    3 years ago

    I too needed more Relpax than what I was given (only 4/month) until my new doctor called in to the pharmacy and I can receive 12/month now. However, I have to get a 3-month supply at a time in order to get the 12/month. The cost for this? Would you believe that WITH insurance it’s almost $2000! I can’t affort that amount every three months.
    I’m back to 4 pills a month, I guess, unless I win the lottery 🙁 Anyone else have this issue? How in the world can we afford the very medication that helps us?!

  • Joanna Bodner moderator
    3 years ago

    Hi Robbie, It is certainly terribly frustrating the cost for these medications! You are not alone sharing in this sentiment! Here is some information on prescription assistance programs you may find helpful (if you haven’t already seen): https://migraine.com/offer-center/prescription-assistance-programs/ and a basic overview of prescription drug insurance that may also be beneficial to review: https://migraine.com/migraine-health-insurance/prescription-drug-insurance/ Lastly, I thought I would share an article addressing this very topic, https://migraine.com/blog/insurance-blessing-curse/, where a fellow migraineur is unable to afford her necessary medication despite good insurance. I agree though…winning the lottery would be a MUCH easier solution! Thanks for being part of our community! Take care, Joanna (Migraine.com Team)

  • MigraineSavvy
    4 years ago

    Here here. Well said. And thanks for sharing that info about the call. So important.

  • MigraMom1
    4 years ago

    I’ve had diagnosed migraine since the late 80’s. Even then the insurance wouldn’t let you have more than 9 pills per month. I would like to know why they think there are only 9 possible chances out of 31 days that a migraineur will have a migraine? It’s not written in stone “Ye Shall Only Suffer Migraine Less Than 9 Days In 31 Days Of The Month” – it’s simply not true. Migraines, at least for me, are unpredictable unless there’s a major trigger present. I have recently been able to get by on simple Excedrin Migraine OTC meds, but sometimes you need stronger stuff. In the mid-90’s, I had injectable Imitrex, which I hated, but the pill form hadn’t come out yet. So I suffered, along with all my fellow migraineurs… Now, I’m limited to meds I can take ahead of time – because I otherwise vomit whatever I take during an attack. I just wish that the triptans were not so very expensive, and could possibly come in patch form or inhalant form. Migraines are very insidious and extremely unpleasant to deal with – why make the remedies so hard to get on top of all that? 9 pills a month? Are they insane? Boo on that.

  • mollyb612
    4 years ago

    Ellen – I have used an inhaled triptan before. I think it was Zomig. I didn’t find that it worked any faster, but it was great if I was nauseated from a migraine.

  • tracey
    4 years ago

    Wow i thought it was expensive to buy them here in Australia but after reading this i now know that they are not that bad also lucky in the fact that I do not have a problem with getting the prescriptions here either,yes not able to take them too often but do not have a limit like I am hearing either feeling very lucky that i do not have to worry as much as you guys hope it gets easier and cheaper for you’se.

  • thenovellife
    4 years ago

    I think I read that same report and wondered how in the world they came up with the number of patients who DON’T take their medication as prescribed. I could not imagine having a prescription for something that would potentially take the proverbial knife out of my head and simply not taking it. The article made me mad so I didn’t go back and read it more thoroughly so what you’re saying makes sense and unfortunately, I can relate.

    I hope you find your pills ~ I know how precious those tiny pill packs are. Good luck!

  • kristen
    4 years ago

    My doctor prescribed me Imitrex to test out for my status migrainosus attacks, and it made me miserable. Pain level 9, miserable. My doctor took me off of it as soon as we talked. Some people may have similar reactions, but may not be as outspoken, and for some reason don’t want to bring it up with their doctor, so they just don’t take the medicine. It may not make sense to you or I, but I’m sure that’s why at least a good group doesn’t take them.

    Or maybe they just aren’t dealing with true migraines. Who knows.

  • deborahvan-der-harst
    4 years ago

    Hi Kerrie, Like you, I am a chronic migraine sufferer. I get a 9 day supply of Maxalt per month. I can only take it two days in a week, and there is a reason for it. I have risk factors for a family history of heart disease, hypertension which is well controlled, Chronic Kidney Disease Stage 3 and elevated cholesterol. My headache specialist told me Maxalt constricts blood vessels, so taking it more than twice a week is too risky for me. I also recently developed a Deep Vein thrombosis near my under arm which adds to the risk. If the Maxalt doesn’t work after 2 days, I have Migranal nasal spray with a two day limit as well. The other two abortives are Orphenadrine Citrate and Valproic Acid. I have the same 2 day limits with them, but they are ineffective, so I usually don’t bother taking them. I call my doctor instead. He sends me to the Emergency Room because his office is almost 2 hours away from me. Once in a great while I take Norco just to get a break from the pain. It doesn’t stop the cycle, so I still need emergency intervention. The Botox is working so that helps me cope when the pain is bad with the knowledge that soon I will be able to get more injections. I hope you find your Amerge, or that your doc will give you another script that your insurance will cover.

  • synetc
    4 years ago

    Another big issue is that some of us can’t take the early Triptans, Imitrex and Amerge because they are sulfonamides. Which is a whole other issue I will write about at some point 😉

    I get 12 Maxalt a month, and it was stressful at first figuring out how to ration them, one time my pharmacy accidentally only gave me 10 and I freaked out (thankfully my pharmacy fixed it without question).

    I am super lucky that I get just enough to manage my attacks without overuse. Somehow both my old insurance and new insurance cover both cover 12, and yes getting the 12 tablets was one of my biggest worries earlier this year.

    I am also “lucky” these days in that I’m having few fully manifested migraines (the only ones a triptan will help me with), instead I’m dealing with basilar aura symptoms and 3+ starts to migraines a day right now, so I oddly have extra Maxalt.

    One of the problems which I have seen with getting triptan limits changed though, is poor patient education. A lot of those new to migraine don’t get proper education on overuse, so they take a triptan daily, get an overuse headache and then the medical community and insurance companies use that as information as to how this should be prescribed to all of us.

    When the reality is that those new to using triptan for migraine didn’t get the information they direly needed from their doctor in the first place. At least once a month I see support posts from people who took their entire 10 tablets of triptan in 10 days and are upset they can’t get more, and are completely unaware of the dangers of taking that many triptans that fast. Also, i think patient education really stinks as to when in an episode taking a triptan is most effective. What kills me about this is that it isn’t new information it’s been the same for 20+ years, before triptans were even around. Money talks and the crucial basics of migraine management are left behind.

  • synetc
    4 years ago

    Correction: I am super lucky that I get just enough to manage my attacks without overuse. Somehow both my old insurance and new insurance cover both cover 12. And yes, getting the 12 tablets with my new insurance was one of my biggest worries when my insurance changed this month.

    Also, I wanted to add, low prescription quantities of abortives goes beyond the Triptan issue. The old drugs which are dirt cheap also have limits including Cafergot and Midrin. It was rare that I’d get a prescription for an amount that would cover 12-15 days for these drugs, and my guess is much of the limit was doctor directed to prevent overuse. No one cares about preventing emergency pharmacy trips in the middle of an attack.

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