Subcutaneously administered Food and Drug Administration (FDA)-approved monoclonal antibodies for calcitonin gene-related peptide may be considered medically necessary for the preventive treatment of episodic or chronic migraine under the following conditions:
The individual is ≥ 18 years of age; AND
Has ≥ 4 migraine headache days per month; AND
Has failed a trial (eg, not effective or not tolerated) from ≥ 3 classes of prophylactic pharmacologic therapies (eg, anti-depressants, anticonvulsants, and beta-blockers, if not contraindicated) AND;
Has not received botulinum toxin headache prophylaxis in the past 4 months.
Intravenously administered FDA-approved monoclonal antibody for calcitonin gene-related peptide may be considered medically necessary for the preventive treatment of episodic or chronic migraine under the following conditions:
The individual is ≥ 18 years of age; AND
Has ≥ 4 migraine headache days per month; AND
Has failed a trial (eg, not effective or not tolerated) from ≥ 3 classes of prophylactic pharmacologic therapies (eg, anti-depressants, anticonvulsants, and beta-blockers, if not contraindicated) AND;
Has not received botulinum toxin headache prophylaxis in the past 4 months.
Galcanezumab may be considered medically necessary for the treatment of episodic cluster headaches under the following conditions:
The individual is ≥ 18 years of age; AND
Individual has been diagnosed with episodic cluster headaches as defined as having at least 2 cluster periods lasting from 7 days to 1 year, separated by pain-free remission periods lasting at least 1 month;
Individua has been unable to achieve a reduction in weekly cluster headache attack frequency with preventative medication(s).
Treatment with monoclonal antibodies for calcitonin gene-related peptide is considered investigational in all other situations including treatment of acute migraine.
