Ask The Pharmacist: Why Migraine Medications in Work Comp Deserve a Closer Review
Michele Page, RPh, MBA
Clinical Director, Client Services
What should I look for before approving a high-cost migraine medication on a claim?
Migraine headaches can be disabling, difficult to document and costly to treat. In workers’ compensation, they also create claim complexity when causation, medication choice or treatment progress is not clearly supported. As newer migraine medications become more common and more expensive, adjusters need to know what to look for in the claim file, when to ask questions and when to escalate for pharmacy review.
The Numbers Tell the Story
For years, migraine medications represented a relatively small share of workers’ compensation pharmacy costs. That is changing. According to Enlyte Drug Trends data, migraine medication costs rose nearly 10% in 2025, the largest prescription cost increase of any drug category. Utilization increased 9.6% during the same period, and migraine medications now rank sixth in overall prescription volume for Enlyte Pharmacy Solutions.
That trend stands out because several other major drug categories, including opioids, anti-inflammatory medications, anticonvulsants and muscle relaxants, were flat or down in 2025. Migraine medications were the exception.
What Makes Migraine Claims Complex
Workplace migraine claims may involve head and neck injuries, whiplash, concussions or exposure to chemicals or environmental factors. High-stress work environments may also worsen an existing migraine condition and raise questions about whether work significantly aggravated a pre-existing condition.
That makes causation important. The claim file should help show whether the migraine condition was caused or was materially aggravated by the work injury or exposure. Without that support, a high-cost medication can continue without a clear connection to the accepted claim.
Adjusters do not need to make clinical decisions but need to identify when the file is missing key information and when a pharmacy, utilization review or peer review resource should take a closer look.
What Is Driving the Cost Increase
A major factor is the growth of CGRP medications, or calcitonin gene-related peptide inhibitors. These medications are used to treat or prevent migraines and may be appropriate for some injured employees. They are also brand-name drugs, with no generic alternatives currently available.
Older migraine medications, such as sumatriptan and rizatriptan, are available as lower-cost generics. When a claim moves to a CGRP medication, the file should show why that medication is needed and whether it is helping the injured employee function.
CGRP Medications at a Glance
Injectable preventive medications can cost $800 to $1,000 per month.
| Generic Name | Brand Name | Common Use |
|---|---|---|
| Erenumab | Aimovig | Monthly injection |
| Fremanezumab | Ajovy | Monthly or quarterly injection |
| Galcanezumab | Emgality | Monthly injection |
| Eptinezumab | Vyepti | Quarterly IV infusion |
Oral and nasal medications may cost up to $1,500 per month.
| Generic Name | Brand Name | Common Use |
|---|---|---|
| Ubrogepant | Ubrelvy | Oral tablet for acute treatment |
| Rimegepant | Nurtec ODT | Dissolving tablet for acute treatment and prevention |
| Atogepant | Qulipta | Oral tablet for prevention |
| Zavegepant | Zavzpret | Nasal spray for acute treatment |
Top Three Migraine Medications
Enlyte Pharmacy Solutions 2025 data show the top three migraine medications were:
- Nurtec ODT, 33.7%, with an average AWP per prescription of $1,994
- Ubrelvy, 17.9%, with an average AWP per prescription of $1,843
- Qulipta, 10.9%, with an average AWP per prescription of $1,365
New Guidelines
In 2023, the American Headache Society updated its position to recognize CGRP medications as a first-line option for migraine prevention. This does not mean CGRPs are the only first-line option. Some patients may warrant alternative therapies before considering a CGRP medication.
For adjusters, this creates a practical challenge. A high-cost migraine medication may be clinically appropriate, but the file should still support why it was selected, how it relates to the compensable condition and whether it is improving function.
New combination medications can also affect costs. For example, Symbravo combines meloxicam and rizatriptan into one tablet. Because those individual components are available as generics, adjusters should watch for premium-priced combination products and escalate when the file does not explain why the combination product is needed.
What Adjusters Should Look For
When a migraine medication appears on a workers’ compensation claim, look for documentation that answers five basic questions.
- Is there a confirmed migraine diagnosis?
The file should support that the medication is treating a migraine condition rather than a tension headache, general pain complaint or another headache disorder. - Is the migraine related to the work injury?
Look for documentation that connects the migraine condition to the accepted injury or exposure. This is especially important when migraines existed before the claim. - What medication is being used and why?
Determine whether the medication is for acute treatment, prevention or both. If a high-cost CGRP or premium combination product is prescribed, the file should explain why that choice is appropriate. - Were lower-cost options tried or considered?
Older medications may still be appropriate for many patients. If a brand-name therapy is prescribed early, the file should show the clinical reason. - Is treatment helping the injured employee function?
Look for signs that treatment is reducing migraine frequency, improving activity tolerance, supporting appointment attendance or helping the injured employee progress toward modified or full duty.
When to Escalate for Pharmacy Review
Consider pharmacy review when:
- A CGRP medication is prescribed without a clearly documented migraine diagnosis
- The file does not show how the migraine condition relates to the work injury
- A high-cost medication is started without documentation that lower-cost options were tried, considered or ruled out
- Refills continue for several months without documented functional improvement
- The injured employee remains off work or restricted, but the file does not show whether migraine treatment is helping
- A premium combination product is prescribed when lower-cost generic components may be available
- The claim involves multiple medications, side effects, delayed recovery or other factors that may affect return to work
Escalation does not mean the medication should be denied. The claim may need clinical review to confirm that the medication is appropriate, supported and aligned with recovery goals.
How Adjusters Can Manage Migraine Medication Risk
Migraine treatment requires balance. Effective care should be supported by the diagnosis, the compensable condition and clear signs of progress.
Adjusters can help maintain that balance by reviewing the claim file for missing information, asking for clarification when documentation is incomplete and involving pharmacy or utilization review when needed.
A practical review should include:
- Confirmed diagnosis
Look for documentation that the injured employee has migraine, not a nonspecific headache complaint. - Work relationship
Check whether the provider explains how the migraine condition was caused or aggravated by the work injury. - Medication rationale
Review why the prescribed medication was selected, especially if it is a CGRP or premium combination product. - Functional progress
Track whether treatment supports fewer migraine days, better activity tolerance, fewer missed appointments or movement toward return to work. - Continued need
Watch for long-term refills without updated documentation of medical necessity or treatment response.
What This Means Going Forward
Migraine medication costs are likely to remain a significant issue in workers’ compensation. New medications will continue to enter the market, clinical guidance will continue to evolve, and more claims may involve migraine treatment after head, neck, concussion or exposure-related injuries.
Adjusters play an important role by identifying unsupported cost drivers early. A well-documented migraine claim should show why the medication is needed, how it relates to the work injury and whether it is helping the injured employee recover or return to work.
When those answers are missing, pharmacy review can help bring clarity to the claim and support treatment decisions that are clinically sound, cost responsible and focused on recovery.
For assistance with a migraine medication review or pharmacy strategy, contact your Client Services Manager or reach out to the pharmacy team at askthepharmacist@enlyte.com.
This information is intended as a general overview. Specific medical or medication-related questions should be reviewed with a health care professional, such as the prescribing physician or dispensing pharmacist.
Do you have a workers’ compensation or auto-related pharmacy question? Send us an email at askthepharmacist@enlyte.com.
To read more Ask the Pharmacist articles, visit enlyte.com/ask-the-pharmacist.