Controversies in migraine management : a technology assessment : final report Tice, Jeffrey A. author. Ollendorf, Daniel A., author. Weissberg, Jed, author. Shore, Karen K., author. Pearson, Steven D., author. Analgesics, Opioid -- therapeutic use Botulinum Toxins, Type A -- therapeutic use Emergency Medical Services Magnetic Field Therapy Migraine Disorders -- drug therapy Migraine Disorders -- economics Migraine Disorders -- prevention & control Migraine Disorders -- therapy Transcutaneous Electric Nerve Stimulation On July 11, 2014, the California Technology Assessment Forum (CTAF) held a meeting in Los Angeles on "Controversies in Migraine Management." The CTAF Panel discussed the clinical effectiveness and reviewed economic analyses of four migraine treatments. Invited policy roundtable experts, including clinical leaders, health plan medical directors, and a patient advocate provided context and interpretation of the review findings. Two devices were considered. First, for the treatment of acute migraine headache accompanied by aura, one well-designed, moderate size study of a single-pulse transcranial magnetic stimulation device (SpringTMS by eNeura) showed superior pain relief compared with a sham device, but no benefit was found in several other common outcome measures. Economic modeling comparing the device with a commonly-used generic triptan found a high relative cost for its potential benefit. Second, only one small trial has been reported of a TENS device (Cefaly) for the prevention of frequent migraine headaches. This trial, further limited by concerns about unblinding and incomplete reporting of adverse effects, showed improvement in some commonly measured headache outcomes. At current pricing and with the best estimate of Cefaly's clinical effectiveness compared with a commonly used generic, oral medication, modeling suggested lower overall benefit and higher cost. For both devices, the CTAF panel voted that the evidence is inadequate to demonstrate that they are as effective as other currently available care options. The CTAF Panel next considered the evidence on BOTOX, the only FDA-approved treatment for the prevention of chronic migraine. Two large, well-designed studies demonstrated improvements in a variety of headache outcomes versus sham injection, but the CTAF Panel voted that inadequate evidence exists to evaluate whether BOTOX is equivalent or superior to other lower-cost oral agents frequently used in this patient population. Subsequent discussion suggested that coverage policies requiring attempts with other treatments before using BOTOX are reasonable and reflect current practice. The CTAF Panel urged that research be performed to allow identification of patients who are better candidates for first-line treatment with BOTOX. Lastly, CTAF examined care options for migraine patients in emergency departments (EDs). These patients receive parenteral opioids over 50% of the time, even though the CTAF Panel confirmed that strong evidence shows that opioids offer no short term benefits compared to other treatment options and raise the long-term risk of exacerbating migraines and of contributing to opioid dependence. The downstream economic impact of such widespread opioid use is also substantial. The CTAF Panel recommended that 1) relevant specialty societies come together to educate patients and providers about the significant harms of opioid use in the ED, and 2) EDs and clinicians develop order sets and use data analysis and feedback to reduce opioid prescribing. [Boston, MA] : Institute for Clinical and Economic Review, August 19, 2014 California Technology Assessment Forum (Organization), issuing body. Institute for Clinical and Economic Review, issuing body. Technical Report Text Illustrations 1 online resource (1 PDF file (v, ES1-ES14, 86 pages)) nlm:nlmuid-101642254-pdf 101642254 http://resource.nlm.nih.gov/101642254 English California United States Reproduced with permission of the copyright holder. Further use of the material is subject to CC BY license. https://creativecommons.org/licences/by/4.0