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Removing Barriers to Appropriate Migraine Treatment: Formulary Limitations and Triptan Package Size


  • Stephen D. Silberstein MD,

  • David Dodick MD,

  • Jim Kesslick MS

  • From the Jefferson Headache Center, Philadelphia, PA (Dr. Silberstein); Mayo Clinic, Scottsdale, AZ (Dr. Dodick); and Independent Consultant, Boyertown, PA (Dr. Kesslick).

Address all correspondence to Dr. Stephen D. Silberstein, Jefferson Headache Center, 111 South 11th Street, Gibbon Building, Suite 8130, Philadelphia, PA 19107.


The main goals in the pharmacologic management of migraine headache are to avert or relieve debilitating pain, prevent escalating acute medication use, and improve day-to-day functioning. This review will examine the evidence supporting the early use of acute medication, usually when pain is mild, to enhance patient outcomes. We will also discuss imposed quantity limits as a practical impediment to the implementation of this strategy in the managed care setting, and will identify strategies for overcoming this barrier to effective care. Quantity limits imposed on triptan therapy by health plans can hinder the optimal acute treatment of migraine. A standard triptan quantity limit sufficient to permit early migraine treatment and a movement by manufacturers to provide blister packs consistent with a standard quantity limit should reduce patients costs, permit brand mobility when appropriate, and bolster long-term cost effectiveness by removing an important impediment to the use of triptans when they are most effective, early in the migraine attack when pain is often still mild.