Aetna headaches nonsurgical coverage & PA

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Selected HCPCS drugs — criteria match / possible prior authorization

Selected HCPCS drugs (e.g., J1110 for dihydroergotamine, J1885 for ketorolac, J3032 for eptinezumab) may require criteria matching and prior authorization. Verify that the member diagnosis and indication match the policy-covered ICD-10 codes and that selection criteria in the policy are documented before billing.

Affected HCPCS: J1110, J1885, J3032
Ensure ICD-10 supports status migrainosus, intractable migraine, cluster headache, or medication overuse headache

Prior Authorization

Device authorization note — neuromodulation devices

Devices used for neuromodulation (noninvasive and implantable) may be subject to device-specific authorization rules. Confirm FDA marketing/clearance status and document indication, patient age, prior conservative therapy trials, and expected treatment regimen.

Document device model and FDA status (e.g., Cefaly: FDA-marketed via De Novo; Nerivio: 510(k) cleared; gammaCore: clearance available)
Include rationale for device use and prior therapy failures

Prior Authorization

Cefaly — authorization note

Cefaly (supraorbital transcutaneous stimulator) is FDA-authorized for migraine prevention in patients ≥18 years and intended for once-daily 20-minute use. Coverage determinations should require documentation of indication, age ≥18, prior preventive therapy attempts, and plan for daily use.

Indication: preventive migraine therapy; age ≥18
Usage: once-daily, 20 minutes
Document prior preventive medication trials and patient training/compliance plan

Prior Authorization

Occipital nerve stimulation (ONS) — prior authorization likely

Occipital nerve stimulation (ONS) and other implantable neuromodulation procedures have limited high-quality evidence and substantial complication rates (e.g., lead migration, implant-site pain). Prior authorization is likely required with detailed supporting documentation of refractory status and prior treatment failures.

Document prior adequate trials of guideline-recommended acute and preventive agents
Include history of occipital nerve block response if performed
Describe expected benefit and plan to manage device complications

Prior Authorization

Prior authorization for invasive neuromodulation

Invasive neuromodulation (e.g., implantable ONS, deep brain stimulation, SPG stimulators) should require prior authorization. Requests should include evidence of severe, refractory headache, prior procedural trials, multidisciplinary evaluation, and risk/benefit discussion.

Required documentation: diagnosis, prior medication and device trials, specialist consultation notes (neurology/neurosurgery)
Describe prior response to less-invasive therapies and objective outcome measures

Prior Authorization

Anti‑CGRP monoclonal antibodies — prior authorization guidance

Anti-CGRP monoclonal antibody therapies (e.g., erenumab, fremanezumab, galcanezumab, eptinezumab) should require prior authorization that documents diagnosis, baseline monthly migraine days, and failure of appropriate prior preventive therapies.

Documentation: baseline monthly migraine days (MMD), prior preventive medication trials and durations, patient-reported outcomes
For continuation: evidence of clinical benefit (reduction in MMD or improved functioning)

Prior Authorization

Inpatient ketamine / lidocaine infusion — prior authorization recommended

Aggressive multi‑day inpatient lidocaine or ketamine infusions for refractory chronic migraine generally require prior authorization and detailed documentation (refractory status, prior protocol failures, monitoring plan). These are considered case‑by‑case when evidence is limited.

Document prior outpatient and Raskin/protocol trials and failures
Include indication (e.g., refractory chronic migraine), planned infusion regimen, monitoring and discharge plan

Prior Authorization

Prior authorization for SPG‑targeted interventions

Sphenopalatine ganglion (SPG) interventions (blocks, stimulation, radiofrequency, vidian neurectomy) have variable evidence; prior authorization is advised. Provide indication, device/applicator details, schedule (e.g., Tx360 twice weekly ×6 weeks), and outcome measures.

Document applicator/device used (Tx360, SphenoCath, Allevio) and dosing/schedule
Provide objective outcome measures and prior treatment history

Prior Authorization

Prior authorization — device and invasive procedures

Prior authorization is generally recommended for devices and invasive procedures (e.g., GON blocks, Nerivio, Cefaly, implantable neurostimulators). Include trial history, targeted examination, and expected measurable outcomes to support medical necessity.

For nerve blocks: targeted history and neurologic exam, laterality and technique
For neurostimulation devices: FDA status, training/compliance plan, prior therapy failures

Note

Prior authorization not specified in this excerpt — verify plan rules

The provided excerpt does not list an explicit, comprehensive prior authorization code list or uniform PA rules for all interventions. Local plan PA requirements should be checked and billing should align with current payer procedures.

No single PA code list is specified in this excerpt
Verify payer-specific PA forms and code lists before submission

Denial Risk

Prior authorization — low‑evidence interventions

Interventions with limited or low-quality evidence (e.g., radiofrequency ablation, epidural steroid injection for cervicogenic headache, photobiomodulation, some infusion therapies) may require prior authorization and strong supporting documentation or may be denied.

Provide literature support, rationale, and prior conservative therapy trials
Be aware that limited evidence increases denial risk

Prior Authorization

Prior authorization guidance — what to submit

General prior authorization guidance: when evidence is limited, invasive, high-cost, or off‑label, request PA with comprehensive documentation — indication, prior therapies, objective outcome measures, device specifics, and monitoring plans.

Attach specialist consultation notes and trial documentation
Include proposed treatment timeline and criteria for continuation or discontinuation

Documentation Required

IV DHE — indications and documentation

IV DHE is considered medically necessary for status migrainosus, cluster attacks unresponsive to oxygen/triptans, intractable severe migraine attacks, and inpatient medication‑overuse headache withdrawal. Off‑label IV DHE use for other headache types may be denied without documentation of intractability.

Indications supporting coverage: status migrainosus (>72 hours), intractable severe attacks, refractory cluster attacks, inpatient MOH
Off‑label/other uses: require strong justification and may be denied

Denial Risk

Insufficient evidence — certain IV or opioid therapies

Certain IV or opioid therapies (e.g., IV valproic acid, IV nalbuphine, IV opioids, IV propofol) have insufficient evidence as routine treatments for acute migraine and may be denied or require strong justification and prior conservative therapy trials.

IV valproic acid: limited and inconsistent evidence for acute migraine
Opioid agonists/antagonists: not recommended routinely; document exceptional circumstances

Note

Device evidence and economic considerations

Device evidence and economic concerns have been raised (e.g., CTAF findings on Cefaly and SpringTMS). Coverage decisions may consider both clinical effectiveness and cost‑effectiveness analyses.

CTAF concluded evidence inadequate to show parity with other care options for some devices
Economic modeling may affect coverage determinations

Note

Evidence gaps for neuromodulation — coverage impact

Evidence gaps exist for many neuromodulation approaches (noninvasive and invasive). Lack of high‑quality randomized multicenter studies and blinding challenges can affect coverage decisions and prior authorization outcomes.

Document why a patient is a candidate despite evidence gaps
Include prior trial data and multidisciplinary opinions

Prior Authorization

gammaCore — 3‑month response rule (NICE)

For gammaCore (noninvasive vagal nerve stimulator), follow‑up and continuation criteria may apply: per NICE guidance, continue therapy only if symptoms improve within the first 3 months.

Document baseline attack frequency and response within 3 months
If no meaningful improvement, justify continued use or discontinue

Denial Risk

IV valproic acid — limited evidence; justify use

IV valproic acid (Depacon) has limited evidence as an acute abortive agent for migraine; it has not been proven superior to comparators and may be considered only with justification after standard therapies fail.

Provide prior treatment failures and rationale if requesting IV valproate
Be aware of alternative recommended agents for acute migraine

Prior Authorization

Ketamine — case‑by‑case use; PA and documentation

Ketamine for migraine and headache disorders is recommended on a case‑by‑case basis in the context of refractory chronic pain; prior authorization should document refractory status, prior failures, proposed regimen, safety monitoring, and informed consent regarding uncertain long‑term effects.

Document previous Raskin or other protocols tried and outcomes
Describe dosing, monitoring, expected benefits, and follow‑up plan

Billing Rule

Ketorolac duration limit — billing and denial risk

Ketorolac (IM/IV) duration limits: adhere to product labeling — total combined duration (injectable plus oral) must not exceed 5 days. Use beyond labeled duration may be denied.

Label limit: ≤5 days combined injectable and oral therapy
Document transitions to alternative analgesics when appropriate

Denial Risk

GONB — documentation risk due to limited evidence

Greater occipital nerve block (GONB) and similar procedures lack standardized protocols and have mixed evidence. Inadequate documentation or nonstandardized protocols may increase denial risk; include targeted history, exam, technique, and response.

Document targeted history, neurologic exam, block technique, and timing of response
Record complete/partial/no relief and duration of benefit

Note

Not all authorization details provided in this document excerpt — verify with payer

Some items and requirements are not specified in this excerpt (e.g., exact PA code lists and uniform step‑therapy rules). Providers must verify specific plan requirements and submit comprehensive documentation to support requests.

No universal PA or step therapy list provided here — check payer portals and PA forms
Include comprehensive clinical records to reduce denial risk

Billing Rule

Ensure supportive ICD‑10 diagnostic codes match covered indications

Supportive ICD‑10 diagnostic codes must align with covered indications in the policy (e.g., status migrainosus, intractable migraine, cluster headache, medication overuse headache). Use these codes when submitting PA requests and claims.

Examples: G43.001 (status migrainosus), G44.001‑G44.029 (cluster headaches), G44.41 (medication overuse headache)
Avoid billing codes for migraine without status/intractable when submitting for IV DHE or other restricted therapies

Documentation Required

Procedure documentation — nerve blocks and SPG procedures

When requesting procedural interventions (nerve blocks, SPG procedures, neurostimulation), include targeted clinical documentation: focused history, neurologic exam, prior therapy trials, device/applicator details, schedule of treatments, and measurable outcome expectations.

For SPG/TX360: provide treatment schedule (e.g., 12 blocks over 6 weeks) and outcome measures
For nerve blocks: specify nerves targeted, technique, and immediate/short‑term response

Documentation Required

Trial procedural and eligibility documentation — what to include

For procedural trials and eligibility (e.g., Tx360 repetitive SPG blockade), include trial schedules, eligibility criteria, baseline measures, and systematic outcome tracking to support medical necessity and continuation.

Include baseline headache frequency/severity and post‑procedure numeric rating scale changes
Define success thresholds and follow‑up timing

Documentation Required

Document response to injections and procedures

Always document the patient's response to injections and procedures (complete, partial, or no relief) with timing and duration of effect. This supports decisions about repeat procedures or escalation to more invasive therapies.

Record time to relief (e.g., minutes), percent reduction in pain, and duration of benefit
Document adverse events or complications

Documentation Required

Document patient selection and outcomes for interventional therapies

Document patient selection and outcomes for interventional and device therapies: baseline attack frequency/severity, medication use, prior preventive failures, and objective outcome measures (e.g., MMD, HIT‑6, MIDAS) to justify initiation and continuation.

Include baseline MMD and change after intervention
Report patient‑reported outcomes and functional improvements

Documentation Required

Documentation for anti‑CGRP therapy (PA support)

Documentation requirements for anti‑CGRP therapy prior authorizations should include diagnosis, baseline monthly migraine days, prior preventive treatment failures (with durations), and patient‑reported outcome measures. For continuation, provide evidence of clinical benefit.

Baseline MMD, prior medication list with dates and reasons for discontinuation
Outcome metrics: reduction in MMD, HIT‑6, MIDAS, or other validated measures

Documentation Required

Documentation for inpatient infusion therapy

For inpatient infusion therapy (lidocaine/ketamine), PA submissions should include refractory diagnosis, prior outpatient protocols tried (Raskin or modified), detailed inpatient regimen, monitoring plan, anticipated length of stay, and discharge/rehab plan.

List prior outpatient treatments and dates of failure
Provide infusion dosing, duration, monitoring frequency, and safety measures

Documentation Required

Inpatient infusion — required documentation details

Inpatient infusion documentation should also state indication (e.g., refractory chronic migraine, medication‑overuse headache), prior protocol failures, expected benefit, and plans for follow‑up and transition to outpatient care.

Include risk/benefit discussion and informed consent notes
Report baseline functional status and post‑infusion plans

Documentation Required

Documentation for SPG / nerve block procedures

When submitting SPG or other nerve block/stimulation procedure requests, document the device/applicator, dosing and schedule, prior response to blocks (if any), and objective measures of efficacy. Lack of standardized protocols may heighten documentation scrutiny.

Specify device (Tx360/SphenoCath/Allevio), volume and concentration of anesthetic, and frequency of treatments
Report numeric outcomes and follow‑up schedule

Documentation Required

Required clinical documentation — neuromodulation and nerve block

Required clinical documentation for neuromodulation and nerve block authorizations should include device FDA status, clinical indication, prior conservative therapy failures, trial results (if applicable), neurologic exam, and objective outcome metrics.

For FDA‑cleared devices (e.g., Nerivio, Cefaly), include clearance documentation and device-specific trial data
For nerve blocks, include targeted history and exam findings

Note

Clinical trials and systematic reviews — use in PA support

This excerpt summarizes clinical trials and systematic reviews for many interventions but does not prescribe exact submission forms. Use the cited evidence to support PA requests where applicable; include trial data and rationale in submissions.

Cite key RCTs or meta‑analyses in PA cover letters when relevant
Attach relevant publications or summaries to support clinical rationale

Documentation Required

Document ICHD‑3 criteria when relevant (e.g., MOH)

For medication‑overuse headache (MOH) diagnosis and related treatment decisions, document ICHD‑3 criteria (headache frequency, duration and specific medication overuse pattern) to support medically necessary interventions such as inpatient withdrawal or IV therapies.

Document headache days/month (≥15 for MOH) and duration of medication overuse (>3 months)
Specify medications overused and dosing frequency to meet ICHD‑3 thresholds

Note

Clinical Policy Bulletin — informational disclaimer and provider responsibility

Clinical Policy Bulletins are partial summaries and not contracts. Providers are responsible for treatment decisions and must verify current plan benefits, PA requirements, and submit necessary documentation to support medical necessity.

Bulletin content is informational — confirm payer‑specific rules
Providers remain responsible for appropriate clinical care and documentation

Step Therapy

Therapeutic sequencing and step therapy expectations

Therapeutic sequencing and stepwise escalation: document adequate trials of first‑ and second‑line acute and preventive pharmacologic therapies (e.g., triptans before ergot derivatives when appropriate) prior to escalation to nonstandard infusions, devices, or invasive procedures.

Detail medications tried, doses, durations, and reasons for discontinuation
For step therapy to devices: document failure or intolerance to pharmacologic and less‑invasive options

Step Therapy

Step therapy for nonstandard and refractory infusion therapies

Step therapy expectations for nonstandard infusions and refractory chronic migraine protocols: require documentation of trials of guideline‑recommended medications and prior protocols (e.g., Raskin) before approval of multi‑day inpatient infusions.

List prior acute and preventive therapies with dates and outcomes
Provide justification for multi‑day inpatient approach and alternatives tried

Step Therapy

Stepwise escalation to interventional therapies — documentation required

Stepwise escalation to interventional therapies (SPG procedures, neurostimulation, surgery) is expected after failure of guideline‑recommended conservative treatments. Provide documented evidence of prior adequate trials and multidisciplinary evaluation.

Document timing and adequacy of prior trials (drug classes, behavioral therapies)
Include specialist consultations and objective outcome measures

Step Therapy

Step therapy considerations for neurostimulators

When considering neurostimulator devices (Nerivio, Cefaly, gammaCore), include step therapy considerations: devices are typically considered after or alongside pharmacologic options and require documentation of prior medication trials, contraindications, or intolerance.

Show prior pharmacologic preventive and acute therapy history
For continuation, provide device‑specific response data and adherence information

Documentation Required

Follow cited clinical guidance and document conservative therapy trials

Clinical guidance cited in this excerpt (NICE, AAN, UpToDate, CTAF) recommends conservative use of experimental adjuncts and thorough documentation of standard therapy trials before attempting experimental or costly interventions.

Follow guideline-recommended trial durations (e.g., 12 weeks for preventive therapies) before declaring treatment failure
Inform patients about uncertainty of efficacy and document consent

Documentation Required

Conservative therapy before experimental adjuncts — document trials

Conservative therapy should be tried before experimental adjuncts; provide clear documentation of standard‑of‑care treatments attempted and reasons for escalation to investigational or low‑evidence modalities.

Document nonpharmacologic measures, preventive drug trials, and response timelines
Attach specialist notes supporting escalation

Note

No step therapy requirements specified here — confirm payer rules

No universal step therapy requirements are specified in this excerpt. Providers must check payer‑specific policies for explicit step therapy rules and preauthorization criteria.

This document does not substitute for payer PA or step‑therapy lists
Confirm current plan policies prior to ordering or billing

Definitions and Key Terms

inv-118: Status migrainosus definition — >72 hours

DefinitionA debilitating migraine lasting more than 72 hours.

RelevanceOne of the most appropriate indications for intravenous DHE; IV administration provides rapid peak plasma levels for status migrainosus.

Clinical settingTypically managed in the ED, urgent care, or hospital; may require multi-day IV DHE administration and possible hospitalization if prolonged therapy needed.

inv-119: DHE (dihydroergotamine) — definition and formulation notes

Agent classDihydroergotamine (DHE) — an ergot derivative used parenterally (IV/IM) or intranasally for acute migraine.

Formulations notedIV, IM, and intranasal DHE formulations are described; orally inhaled DHE (MAP0004) has been studied in trials but is distinct from parenteral/intranasal forms.

Clinical roleIV DHE is most effective when rapid effect is desired or for intractable severe headache (status migrainosus, transformed migraine, rebound headache) and cluster headache.

inv-120: Supraorbital transcutaneous stimulator (STS/Cefaly) — device definition

Device typeSupraorbital transcutaneous stimulator (STS/Cefaly) — a transcutaneous electrical nerve stimulation device applied to the forehead to stimulate trigeminal nerve branches.

ApplicationDevice is worn across the forehead with a self-adhesive electrode positioned above the eyes; applied once daily for 20 minutes in adults per FDA clearance.

IndicationFDA-cleared for migraine prevention in adults (age ≥18).

inv-121: Chronic Cluster Headache (CCH) — definition summary

Definition summaryChronic cluster headache (CCH) is a form of cluster headache with chronic periodic attacks that are often medically intractable; small open-label studies have evaluated treatments (eg, sodium oxybate).

Clinical featuresSevere unilateral periorbital pain with autonomic symptoms; nocturnal attacks may disrupt sleep and CCH comprises ~10% of cluster cases.

Evidence statusExisting evidence for some pharmacologic approaches is limited and largely from small open-label studies; well-designed trials are needed.

inv-122: Refractory headaches — definition as used in policy

Policy definitionRefractory headaches: headaches in patients who, after adequate trials of specific acute or prophylactic drugs, fail to reduce disease burden or improve headache-related quality of life.

Clinical implicationRefractory status often prompts consideration of escalated therapies including neurostimulation or invasive options after specialist evaluation.

Recommended approachAddress comorbid factors and use an escalating/stepwise approach; consider invasive modalities only after adequate trials of standard therapies have failed.

inv-123: Cefaly — device definition and FDA-cleared indication

Device descriptionCefaly is a prescription transcutaneous electrical nerve stimulation (TENS) headband worn across the forehead, applying current to stimulate trigeminal nerve branches.

FDA-cleared indicationCleared by FDA as a preventive treatment for migraine in adults; intended once-daily 20-minute sessions.

User instructionPosition device center on forehead above the eyes using a self-adhesive electrode; user may feel tingling or massaging sensation at electrode site.

inv-124: Medically intractable chronic migraine (CM) — definition and population evaluated

Definition / criteriaMedically intractable chronic migraine: headache disorder with ≥15 headache days per month and refractory to conventional medical treatments; population evaluated in ONS trials.

Trial contextONS feasibility and other trials enrolled patients meeting chronic migraine criteria (eg, ≥15 days/month) and often required prior conservative therapy trials.

Clinical implicationConsider invasive neuromodulation only for severe, medically refractory chronic migraine after multiple preventive failures and specialist assessment.

inv-125: Chronic migraine (CM) — trial definition (15+ days/month, 8+ migraine days)

Trial definitionChronic migraine defined in trials (eg, erenumab) as ≥15 headache days per month, of which ≥8 are migraine days.

Measurement periodDefinition applied to baseline and outcome assessments in chronic migraine prevention trials.

Implication for coverageEligibility for certain therapies in policy references trial definitions when documenting baseline monthly migraine days.

inv-126: nVNS (noninvasive vagus nerve stimulation) — definition and devices (gammaCore)

DefinitionNoninvasive vagus nerve stimulation (nVNS) is a portable device (eg, gammaCore) delivering transcutaneous stimulation to the vagus nerve for acute or preventive use in cluster headache and migraine.

Devices citedgammaCore is an example of nVNS studied for cluster headache and migraine with some supportive trial data; NICE recommends continuation only if symptoms reduce within 3 months.

Evidence caveatOverall efficacy is variable across studies; trials vary in design and quality and require documented response for ongoing use per guidance.

inv-127: Chronic migraine — restated definition (15+ days/month)

Restated definitionChronic migraine: 15 or more headache days per month, of which 8 or more are migraine days.

Use in trialsThis definition was used as eligibility in pivotal chronic migraine trials such as erenumab studies.

Documentation notePolicy references trial-based definitions when requiring baseline monthly migraine day counts for therapy authorization.

inv-128: Open-label extension (OLE) — definition

DefinitionOpen-label extension (OLE): a study phase after a randomized controlled trial in which participants receive active treatment and are followed for long-term safety and efficacy without a placebo control.

PurposeUsed to collect long-term safety/efficacy data and to observe durability of treatment effects beyond the randomized phase.

ExampleErenumab OLE reported sustained reductions in monthly migraine days and responder rates at 1 year in observed analyses.

inv-129: Responder rate (in ketamine studies) — definition

DefinitionResponder rate: proportion of patients meeting predefined improvement criteria (eg, pain relief or reduction in headache days); used as an outcome measure in ketamine studies.

ContextSome ketamine trials reported higher responder rates versus placebo despite heterogeneity and risk of bias across studies.

ImplicationResponder rate informs clinical decisions on short-term benefit but must be interpreted given study limitations and low-certainty evidence.

inv-130: Refractory chronic migraine (rCM) — definition and lack of standardization

DefinitionRefractory chronic migraine (rCM): patients with chronic migraine who have failed multiple standard treatments; there is no widely accepted standardized set of diagnostic criteria.

Evidence gapAuthors note lack of standardized criteria hampers research and treatment comparisons; calls exist for consensus definitions to guide therapy and trials.

Clinical userCM patients may be considered for aggressive inpatient infusion protocols or neuromodulation on a case-by-case basis with documented prior failures.

inv-131: Transcutaneous supraorbital neurostimulation (tSNS / eTNS / Cefaly) — device definition

Device typeTranscutaneous supraorbital neurostimulation (tSNS / eTNS / Cefaly) — a device-based supraorbital TENS therapy for migraine prevention.

EvidenceRandomized trial evidence in episodic migraine showed higher responder rates vs sham (eg, 38.1% verum vs 12.1% sham in a 67-patient trial).

ApplicationApplied once daily for ~20 minutes; FDA-cleared for preventive use in adults; effectiveness in chronic migraine less certain.

inv-132: Ketorolac tromethamine (intramuscular) — drug definition and label constraints

Drug identityKetorolac tromethamine (intramuscular) — an NSAID indicated for short-term management of moderately severe acute pain.

Label constraintsProduct labeling requires initiation with IV or IM dosing and limits total combined duration of ketorolac injection plus oral use to ≤5 days due to safety concerns.

Typical dosing notedTrials and practice commonly use 60 mg IM for acute migraine in ED or physician-supervised settings.

inv-133: External trigeminal nerve stimulation (eTNS) — definition

DefinitionExternal trigeminal nerve stimulation (eTNS) is a noninvasive neurostimulation approach (eg, Cefaly) targeting trigeminal nerve branches for migraine prevention.

EvidenceSmall sham-controlled trials and imaging studies suggest possible efficacy for episodic migraine, but studies are limited and underpowered; mechanism remains unclear.

Regulatory statusDevices such as Cefaly have regulatory clearance for migraine prevention in adults.

inv-134: Sphenopalatine ganglion (SPG) block/stimulation — definition

DefinitionSphenopalatine ganglion (SPG) block/stimulation: procedures targeting the SPG (block, stimulation, radiofrequency, radiosurgery, vidian neurectomy) investigated for cluster headache and migraine.

Reported outcomesReported efficacy ranges widely across modalities (eg, SPG block efficacy up to 76.5% in some series; stimulation outcomes variable), but evidence is heterogeneous and placebo-controlled trials are limited.

Clinical recommendationPlacebo-controlled studies and collaboration between neurologists and ENT specialists recommended to define indications and optimal techniques.

inv-135: Manual therapy — definition

DefinitionManual therapy: physical techniques (eg, mobilization, manipulation) applied to treat tension-type and migraine headaches aiming to improve health-related quality of life.

Evidence summarySystematic reviews report small-to-moderate improvements in HR-QOL measures (eg, HIT-6) but overall evidence quality is very low; interpret cautiously.

RoleConsidered an adjunctive treatment rather than a primary evidence-based therapy given current low-certainty data.

inv-136: Greater occipital nerve block (GONB) — definition

DefinitionGreater occipital nerve block (GONB): injection of local anesthetic, with or without steroid, around the greater occipital nerve for cluster, cervicogenic, and migraine headaches.

EvidenceSystematic reviews/meta-analyses report reductions in pain intensity, headache days, and medication consumption but with heterogeneous protocols and outcomes; pooled 1-month pain-free proportion ~50% in CH studies.

DocumentationIf used clinically or for coverage, require documentation of indication, prior conservative therapy failure, procedural details (agent, laterality, timing), and patient response.

inv-137: Remote electrical neuromodulation (REN) / Nerivio — definition and FDA clearance

DefinitionRemote electrical neuromodulation (REN, Nerivio): an FDA-cleared, non-invasive, upper-arm electrical stimulation device applied within 1 hour of migraine onset for acute treatment using conditioned pain modulation.

Efficacy evidenceMulti-center RCT (n=252) showed active REN superior to sham for pain relief at 2 hours (66.7% vs 38.8%) and pain-free rates (37.4% vs 18.4%).

Regulatory statusDevice is FDA-cleared via 510(k) for acute treatment of migraine in adults (non-chronic migraine).

inv-138: Post-dural puncture headache (PDPH) — definition

DefinitionPost-dural puncture headache (PDPH): headache occurring after lumbar puncture or dural puncture; sometimes treated conservatively or with pharmacologic agents such as caffeine or cosyntropin.

Evidence summaryCochrane review of 13 small RCTs (479 participants) found caffeine reduced PDPH at 1–2 hours and decreased need for supplementary therapy; overall evidence limited by small trials.

Clinical noteOral caffeine (300–500 mg once or twice daily) recommended in some guidance; IV caffeine used when oral intake not possible.

inv-139: Chronic pain — IASP definition (>3 months)

DefinitionChronic pain: pain that persists or recurs for longer than 3 months (IASP definition).

Clinical relevanceChronic pain principles inform management decisions in refractory headache populations and the need for multidisciplinary approaches.

ImplicationMany interventions for chronic headache consider chronic pain frameworks when assessing long-term outcomes and risks.

inv-140: Refractory chronic cluster headache (rCCH) — definition per cited review

DefinitionRefractory chronic cluster headache (rCCH): chronic cluster headache not responsive to standard therapies as defined by European Headache Federation consensus used in cited systematic review.

EvidenceMost studies in rCCH examine neuromodulation techniques (eg, ONS, DBS) with pooled response rates reported but heterogeneity and variable adverse events across modalities.

Clinical implicationInterventional therapies for rCCH may be considered after failure of standard therapies but require careful specialist evaluation and discussion of risks.

inv-141: Medication overuse headache (ICHD-3) — definition and thresholds

ICHD-3 definitionMedication overuse headache: headache occurring on ≥15 days/month in a patient with a pre-existing headache disorder plus regular overuse for >3 months of acute/symptomatic medications per specified thresholds.

Overuse thresholds≥10 days/month for ergotamines, triptans, opioids, or combination analgesics; ≥15 days/month for simple analgesics; duration >3 months.

Diagnostic notePatients meeting criteria for both medication overuse headache and chronic migraine should receive both diagnoses per ICHD-3 rules.

inv-142: Peripheral neurostimulation / Occipital nerve stimulation — definition

DefinitionPeripheral neurostimulation / Occipital nerve stimulation: implanted or external electrical stimulation targeting peripheral cranial nerves (eg, occipital nerves) investigated for refractory chronic migraine and cluster headache.

Evidence summaryONS trials show mixed efficacy with notable device-related complications (eg, lead migration rates reported up to ~24%); pooled response rates in reviews vary and quality of evidence is limited.

Clinical considerationUse generally reserved for severe, medically refractory cases after specialist assessment and documented prior therapy failures; prior authorization or special arrangements may be appropriate given evidence uncertainty.

96365	Intravenous infusion, for therapy, prophylaxis, or diagnosis; initial, up to 1 hour.
96372	Therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular.

J1110	Injection, dihydroergotamine mesylate, per 1 mg.
J3032	Injection, eptinezumab-jjmr, 1 mg.
J1885	Injection, ketorolac tromethamine, per 15 mg.
J0706	Injection, caffeine citrate, 5 mg.

64405	Injection(s), anesthetic agent(s) and/or steroid; greater occipital nerve.
83520	Immunoassay for analyte other than infectious agent antibody or infectious agent antigen, quantitative; not otherwise specified.
97140	Manual therapy techniques, 1 or more regions, each 15 minutes.

A4540	Distal transcutaneous electrical nerve stimulator, stimulates peripheral nerves of the upper arm.
C9290	Injection, bupivacaine liposome, 1 mg.
J1170	Injection, hydromorphone, up to 4 mg.
J2001	Injection lidocaine HCL for intravenous infusion, 10 mg.

G43.001	Migraine with status migrainosus and/or intractable.
G44.001 - G44.029	Cluster headaches (example range).

OpenPayer

Headaches: Nonsurgical Management

Coverage Criteria — Nonsurgical Headache Treatments

Coding — Procedure, Drug, and Diagnosis Codes

Provider Actions, Prior Authorization, and Documentation

Background and Scope

Definitions and Key Terms

Policy Dates and Revision History