Session 6 - Nordic reimbursement guidelines for aCGRP treatment

Lars Jacob Stovner

MD, PhD, Professor of Neurology, Norwegian University of Science and Technology and Norwegian Advisory Unit on Headaches, St. Olavs Hospital, Trondheim, Norwayk

The Norwegian Health Economic Administration (HELFO) administers the ‘Blue Prescription’ national insurance scheme under which the costs of medicines are reimbursed. Unlike other migraine treatments, anti-CGRP monoclonal antibodies are not covered by this scheme. Instead, their cost is reimbursed on individual application which must be renewed annually. The application can be made by a neurologist or a doctor working at the neurology department, or a doctor in a private hospital employing at least one neurologist. Treatment of patients aged under 18 is an unlicensed use but the same doctors and also a pediatrician are eligible to make the application.

Eligible patients have chronic migraine according to ICHD-3 criteria. The application must document migraine severity (monthly migraine headache days), previous preventive therapy, evidence of medication overuse headache and state that discontinuation of acute treatments has been attempted. Previous treatment with one of at least three pharmacological classes must have been unsuccessful. This may have been due to lack of effectiveness or adverse effects but contraindication is not considered a valid reason for not attempting treatment. For patients who have chronic migraine despite treatment with onabotulinum toxin A and who wish to start with an anti-CGRP monoclonal antibody it is recommended that this is done at least 4 months after the last injection, but if an increase in migraine cannot be tolerated, it can also be done immediately. Either way, if CGRP antibodies seem to work, one should try to discontinue onabotulinum toxin A, but in some cases both medicines may be necessary.

The patient must keep a headache diary. Treatment should be reviewed after 3 months and continued only if headache days (severity 2–3 on a scale of 0–4) were reduced by ≥30% during the previous 4 weeks. Clinicians are allowed discretion when interpreting the effectiveness criteria – for example, effectiveness may mean the patient manages with less acute medication, migraine