ModifiedPremera BluecrossPolicy N/A

Migraine and Cluster Headache Medications

Defines medical necessity, quantity limits, and step requirements for pharmacy-covered medications used to treat acute migraine and cluster headaches for members under the payer's pharmacy benefit.

Policy Summary

PayerPremera Bluecross

PolicyMigraine and Cluster Headache Medications (coverage criteria for acute and preventive therapies)

Policy CodePolicy N/A

Change TypeMaterial updates to product-specific trial requirements and removals for market-exited drug

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting diagnosis, medication trials and dosing to support prior authorization requests managed through the pharmacy benefit.

SourceLink

POLICY UPDATE CHANGES

Removed coverage criteria for Amerge (naratriptan) because it was removed from the market.

Updated Symbravo (rizatriptan/meloxicam) criteria to require trial of 2 different generic triptan medications and removed prior requirement regarding trial of generic rizatriptan with 2 generic NSAIDs and exclusion for medication overuse.

Updated generic sumatriptan/naproxen and Treximet criteria to require trial of 2 different generic triptans and removed prior NSAID-combination and medication overuse requirement.

Updated Elyxyb (celecoxib oral solution) criteria to require trial of 2 different generic triptans and removed the medication overuse exclusion.

Updated dihydroergotamine product criteria (Atzumi, Brekiya, Trudhesa, Migranal, generic DHE) to remove medication overuse exclusions and to add age and prior-triptan trial requirements for some generics (age ≥18 and trial of ≥2 different generic triptans with one non-oral route).

Updated several dihydroergotamine and ergotamine product criteria to require trial and inadequate response or intolerance with generic ergotamine or dihydroergotamine, and adjusted triptan trial requirements for some products.

18/30dcommon tablet quantity limit

8/30d

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Coverage Criteria for Acute Migraine and Cluster Headache Therapies

Generic triptans — initial and additional quantities

Generic triptan medications may be considered medically necessary for the acute treatment of migraine and cluster headaches when ALL of the following criteria are met:

Generic triptans baseline: Quantity dispensed does not exceed: 18 tablets per 30 days OR 8 injections per 30 days OR 18 nasal sprays per 30 daysquantity limits

from general generic triptan section

Escalation for migraine: For additional quantities for migraine: the individual has failed a trial of a different triptan prior to dose escalation AND the prescription is for less than 30 doses per 30 days AND doses do not exceed FDA labeled maximum daily doses AND the individual is not experiencing medication overuse headache(s) AND has unsuccessfully tried at least 3 categories of prophylactic migraine headache therapies listed in the Appendix (unless contraindicated)step therapy and limits

applies to dose escalation

Escalation for cluster: For additional quantities for cluster headaches: the individual has unsuccessfully tried at least 3 categories of other abortive cluster headache therapies listed in the Appendix (unless contraindicated) AND has unsuccessfully tried at least 3 categories of prophylactic cluster headache therapies listed in the Appendix (unless contraindicated) AND the prescription is for less than 30 doses per 30 days AND doses do not exceed FDA labeled maximum daily doses AND the individual is not experiencing medication overuse headache(s)step therapy and limits

cluster-specific escalation

Brand triptans — coverage criteria

Brand triptans listed may be medically necessary when ALL of the following are met:

Brand triptans baseline: Quantity dispensed does not exceed: 18 tablets per 30 days OR 8 injections per 30 days OR 18 nasal sprays per 30 days (formulation-dependent)quantity limits

brand examples provided

Brand triptan prior trials: Has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications in any dosage form (oral, injectable, or nasal) when required by the specific brand's criteriastep therapy

brand-specific requirement documented for certain products (e.g., Onzetra, RizaFilm, Zembrace, Zomig 2.5 mg)

Brand escalation: For additional quantities: prescription is for less than 30 doses per 30 days AND doses do not exceed FDA labeled maximum daily doses AND the individual is not experiencing medication overuse headache(s) AND has unsuccessfully tried at least 3 categories of prophylactic migraine therapies listed in the Appendix (unless contraindicated); for cluster headaches additional criteria include unsuccessful trials of at least 3 abortive and 3 prophylactic categories as appropriate

Combination triptan/NSAID products

Combination products may be considered medically necessary when ALL of the following are met:

Symbravo (rizatriptan/meloxicam): Individual aged ≥18 AND has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications AND quantity limited to 18 tablets per 30 days. Additional quantities require unsuccessful trial of at least 3 prophylactic categories and prescription <30 doses/30 days.age and step

Symbravo-specific

Sumatriptan/naproxen (generic) & Treximet (sumatriptan/naproxen): Individual aged ≥12 AND has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications AND quantity limited to 18 tablets per 30 days. Additional quantities require unsuccessful trial of at least 3 prophylactic categories and prescription <30 doses/30 days.age and step

sumatriptan/naproxen-specific

Elyxyb (celecoxib oral solution)

Elyxyb may be considered medically necessary for acute migraine when ALL of the following are met:

Elyxyb baseline: Individual aged ≥18 AND has tried and had an inadequate response from at least 1 NSAID during previous migraine episode(s) AND has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications OR has a contraindication to triptans AND quantity limited to 12 bottles (120 mg/4.8 mL per bottle) per 28 days.age and prior trials

Elyxyb-specific

Elyxyb escalation: Additional quantities: individual aged ≥18 AND prior NSAID and triptan requirements met OR contraindication to triptans AND has unsuccessfully tried at least 3 categories of prophylactic migraine therapies listed in the Appendix (unless contraindicated) AND doses do not exceed FDA labeled maximum daily doses.escalation

Elyxyb additional quantity criteria

Ergot derivatives — coverage criteria

Ergot derivative products may be considered medically necessary when ALL of the following are met (product-specific limits apply):

Atzumi (dihydroergotamine) nasal spray: Individual aged ≥18 AND has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications with at least 1 product having a non-oral route AND has tried and had an inadequate response to generic dihydroergotamine nasal spray AND quantity limited to 12 doses per 30 days. Additional quantities require unsuccessful trial of at least 3 prophylactic categories and doses ≤ FDA maximum daily doses.age, step, quantity

Atzumi-specific

Brekiya (dihydroergotamine) injection: Individual aged ≥18 AND has tried and had an inadequate response or intolerance to at least 2 different generic triptan medications with at least 1 product having a non-oral route AND has tried and had an inadequate response to generic dihydroergotamine AND quantity does not exceed 24 doses (24 mL) per 30 days. Additional quantities require unsuccessful prophylactic trials and doses ≤ FDA maximum daily doses.age, step, quantity

Brekiya-specific

Non-triptan acute migraine agents — coverage criteria

Non-triptan acute migraine agents may be considered medically necessary when ALL of the following are met:

Nurtec ODT (rimegepant): Individual aged ≥18 AND has had an inadequate response or intolerance to at least 1 triptan OR has a contraindication to triptans AND Nurtec ODT is not used concurrently with Ubrelvy or Zavzpret AND quantity limited to 8 tablets per 30 days. Additional quantities: aged ≥18 AND prior triptan trial or contraindication AND has unsuccessfully tried at least 2 categories of prophylactic migraine therapies AND not used concurrently with Ubrelvy or Zavzpret AND quantity limited to 16 tablets per 30 days.age, step, concurrency, quantity

Nurtec-specific

Reyvow (lasmiditan): Individual aged ≥18 AND has had an inadequate response or intolerance to at least 1 triptan OR has a contraindication to triptans AND quantity limited to 8 tablets per 30 days. Additional quantities: aged ≥18 AND prior triptan trial or contraindication AND is not experiencing medication overuse headache(s) AND has unsuccessfully tried at least 3 categories of prophylactic migraine therapies AND quantity up to 16 tablets per 30 days.age, step, quantity

Reyvow-specific

Coverage criteria (summary)

Coverage includes acute and preventive migraine therapies managed through the pharmacy benefit; specific product criteria require trials of other agents as detailed in product sections.

Pharmacy benefit application: Policy applies to members under the Company's Pharmacy Formulary; quantities may be limited in a rolling 30-day period and exceptions require medical record review.rolling 30-day

applies to pharmacy benefit only; not Express Scripts

Triptan step requirements: Several product updates require trial and failure of one or two different generic triptan medications prior to coverage of certain combination or alternative agents (e.g., Symbravo, sumatriptan/naproxen products, Elyxyb).trial of 1-2 different generic triptans depending on product

2023-2026 updates adjusted number of required triptan trials

Dihydroergotamine criteria: Certain DHE products now require trial and inadequate response or intolerance to generic ergotamine or dihydroergotamine; for generic DHE nasal spray and Migranal the individual must be ≥18 years and have tried at least 2 different generic triptans with one non-oral route.

Product-specific trial and step therapy requirements

Updates and product-specific coverage rule changes summarized in this section include:

Dihydroergotamine/Ergotamine product requirements: For certain branded ergot/dihydroergotamine products (Ergomar, Migranal, Trudhesa, Atzumi, Brekiya), coverage requires prior trial and inadequate response or intolerance to generic ergotamine or generic dihydroergotamine; for some generic dihydroergotamine nasal spray and Migranal, the individual must be >=18 years and have tried >=2 different generic triptans with at least one non-oral route.see product-specific criteria

Removed medication-overuse-headache exclusion for several products in 2026 update.

Triptan trial requirements: For several products (Symbravo, generic sumatriptan/naproxen, Treximet, Elyxyb), coverage criteria now require trial of two different generic triptans instead of prior combination/NSAID-specific trials; requirements that individuals not be experiencing medication overuse headaches were removed for multiple products.two different generic triptans

One triptan product may need a non-oral route for certain ergot criteria.

Product-specific trial and step therapy requirements

Policy updates indicate the following adult-focused requirements for coverage:

CGRP acute use: Requires trial and failure of one triptan prior to coverage for acute CGRP therapies.trial and failure of 1 triptan

Updated 10/01/23 and clarified 11/03/23

CGRP preventive use: Requires trial and failure of two prophylactic medications prior to coverage for preventive CGRP agents.trial and failure of 2 prophylactic medications

Updated 10/01/23 and clarified 11/03/23

Dihydroergotamine nasal/injection products: Certain branded/novel DHE products require age ≥18, trial of at least one non-oral triptan, trial of generic dihydroergotamine nasal spray, and are limited to specified doses per 30 days (e.g., Atzumi/Trudhesa limited to 12 doses per 30 days; Brekiya injection limited to 24 doses/24 mL per 30 days).

All other uses of the medications listed in this policy are considered not medically necessary.

Amerge (naratriptan) coverage criteria were removed from this policy because the product was removed from the market and is no longer applicable for coverage.

Amerge (naratriptan) has been removed from the policy for the same reason noted above: the product was withdrawn from the market and coverage criteria were eliminated.

Policy history documents the removal of coverage criteria for Amerge (naratriptan) during the 05/01/26 annual review after the product was removed from the market; related changes to triptan and ergot criteria are recorded in the same history entry.

All other uses of the medications listed in this policy are considered not medically necessary.

Medication overuse of abortive agents is recognized as a clinical concern because it can increase headache frequency and reduce control and quality of life. The policy previously included medication-overuse restrictions for several products; those requirements were removed for multiple agents in the 2026 updates.

Because Amerge (naratriptan) was removed from the market, criteria and coverage language referring to this product are no longer applicable and have been removed from the policy.

Coding

CodingN/A

No codes listed

Codingmixed

No codes listed

Historical coding changesmixed

No codes listed

Provider Actions, Prior Authorization, and Documentation

Prior Authorization

Pharmacy benefit prior authorization

This policy is managed through the pharmacy benefit. The limitation of migraine headache therapies in a rolling 30-day period is in conformance to member contracts, which state quantities may be limited based on medical necessity. Exceptions to pharmacy prior authorization duration and/or quantity limitations will be made on a case-by-case basis after review of individual medical records. Non-formulary exception review authorizations for drugs listed in this policy may be approved for up to 12 months. All drugs in this policy are subject to the product's FDA dosage and administration prescribing information.

Managed through pharmacy benefit (applies to enrollees on the Company's Pharmacy Formulary)
Express Scripts Formulary enrollees are not covered by this policy
Quantity limits applied on a rolling 30-day period per member contract
Exceptions to prior authorization duration/quantity limits considered case-by-case with medical record review
Non-formulary exception approvals may be granted up to 12 months (clarified 2025)
All listed medications are subject to FDA dosage and administration prescribing information

Background

Migraine and cluster headaches are distinct, often severe primary headache disorders. Migraine commonly presents with unilateral, pulsatile head pain and may be accompanied by nausea, photophobia and phonophobia; cluster headache causes severe unilateral periorbital pain with autonomic features. Acute treatment options addressed in this policy include triptans, ditans, gepants, ergot derivatives, NSAIDs and other abortive therapies, and preventive options include a variety of prophylactic medications and CGRP-targeted agents. Overuse of acute abortive medications can lead to medication overuse headache, worsening headache frequency and decreased function, which is an important clinical consideration when evaluating requests for additional quantities or escalation of therapy.

Definitions

Medication overuse headache(s)

DefinitionMedication overuse headache: increased headache frequency associated with excessive use of acute headache medications; policy notes overuse can worsen headache frequency and that medication-overuse requirements were removed for several products in recent updates.

Policy relevancePreviously used as an exclusion/contraint for some product approvals; multiple 2025–2026 updates removed the 'not experiencing medication overuse headaches' requirement for several drugs.

Clinical concernDocument acknowledges medication overuse is a recognized problem and historically informed step/quantity limits to avoid worsening headache frequency.

Triptan medications — definition

ClassTriptans (5-HT1B/1D receptor agonists)

Mechanism

Policy Summary

PayerPremera Bluecross

PolicyMigraine and Cluster Headache Medications (coverage criteria for acute and preventive therapies)

Policy CodePolicy N/A

Change TypeMaterial updates to product-specific trial requirements and removals for market-exited drug

Effective DateMay 1, 2026

Next Review DateN/A

Key ActionSubmit medical records documenting diagnosis, medication trials and dosing to support prior authorization requests managed through the pharmacy benefit.

SourceLink

On This Page

Documentation Required

Required documentation for prior authorizations

Providers must submit medical records demonstrating that medical necessity criteria are met. The individual's chart should include office visit notes with diagnosis, relevant history, physical evaluation, and medication history. Documentation supporting an exception to standard duration or quantity limits should be included when requesting case-by-case review.

Office visit notes with diagnosis, relevant history, physical exam, and medication history required
Attach documentation of prior trials, intolerances, contraindications, and response to therapy when requesting exceptions
Specify requested quantity and rationale for exceeding standard limits

Denial Risk

Exceptions, denial risk, and approval length

Exceptions to pharmacy prior authorization duration and quantity limits will be handled on a case-by-case basis; absence of supporting documentation or failure to meet required trials/criteria may result in denial. Quantity limits are enforced per rolling 30-day period and exceeding those limits without an approved exception risks claim denial.

Denial risk if required trials (e.g., triptan trials, ergot/dihydroergotamine trials) are not documented
Drugs removed from market (e.g., Amerge) are no longer covered; requests for such agents will be denied
Prior authorization approvals may be issued up to 12 months when criteria met and documentation supports ongoing benefit

Step Therapy

Step therapy and prior trial requirements (provider action)

Some therapies require prior trials or step therapy before approval (for example, trials of generic triptans or specific ergot/dihydroergotamine products as reflected in drug-specific coverage criteria). Missing required step therapy trials is a common trigger for denial; provide documented trials or contraindications to avoid denial.

Step therapy requirements and required trial documentation must follow the drug-specific criteria in the policy (e.g., trials of 2 different generic triptans for certain products)
For ergot derivatives, document trials of required generic ergotamine or dihydroergotamine when specified
If a medication has been removed from the market (e.g., Amerge), do not request coverage

Medication overuse headache — historical note

Historical notePolicy historically required that individuals not be experiencing medication-overuse headaches for some product approvals, but multiple 2025–2026 updates removed that requirement for several drugs.

Specific changes2026 update removed medication-overuse-headache requirements for Atzumi, Brekiya, Trudhesa, generic DHE, Elyxyb, and certain triptan/combination products; criteria were otherwise updated to require specified triptan or prophylactic trials.

ImplicationMedication overuse remains a clinical concern, but the policy now emphasizes prior trials, age, and route-of-administration criteria rather than a blanket absence-of-overuse requirement for many products.