Rendered Unaffordable: new non-funded migraine medications remain out of reach for patients

NEWS | RONGOA / DRUGS

Written by Melissa Irving (she/her) | @the_vintage_journalist | Contributing Writer

Migraine creeps up on me slowly like nightfall, almost imperceptibly at first, an irreversible culmination of factors that fall into place until I am plunged into darkness. I am pinned down by the throes of inconceivable, debilitating pain, nausea, light and sound sensitivity, wondering how I will last through this night.

Struggling through a cascade of migraine attacks led me to investigate if New Zealand’s current regime of funded medicines are sufficient for managing the condition.

Migraine (māhunga ānini) is an incurable, complex neurological disease with a genetic basis. Believed to be the fourth leading cause of disability in Aotearoa, it is most common in working age people and affects women two to three times more than men. In recent years, there have been a number of new medications which have been developed to specifically treat migraine disease. While I was nursing yet another migraine attack, I was disheartened to discover that New Zealand funds very few pharmaceutical options that treat migraine disease more effectively.

According to Migraine Foundation Aotearoa, two of these new medications (Calcitonin Gene-Related Peptide [CGRP] monoclonal antibody preventatives) are available for prescription, but they are not funded by Pharmac. Currently, this means that people have to self-fund these medicines at a prohibitively high cost, rendering them as being largely unaffordable and inaccessible for patients.

Dr Fiona Imlach, public health physician and co-founder of Migraine Foundation Aotearoa, says that it is promising to see more research being conducted and new treatments becoming available after many years of limited options.

“It is amazing to finally have some hope for new treatments which we haven’t had for decades. We haven’t had anything since the triptans and that was from the 1990s,” says Dr Imlach. 

However, this hope is dampened by frustration at how financially prohibitive the costs of these medications are and the negative effect this has on the quality of life for patients with migraine disease.

“But if they’re not accessible or affordable for you, then it’s a very harsh hope isn’t it?,” says Dr Imlach.

Since 2022, Migraine Foundation Aotearoa have advocated how crucial it is that New Zealand expands our funded migraine treatment options. Dr Imlach highlighted that CGRP monoclonal antibody preventatives are hugely beneficial because they do not have many contraindications and they are tolerated better by patients with fewer side effects. They are suitable for patients with chronic migraine, as they will not induce a medication overuse headache like triptans or analgesics can and these drugs will help to alleviate existing medication overuse headaches, says Dr Imlach. Additionally, CGRP monoclonal antibody preventatives work well for addressing anxiety and depression which are common comorbidities alongside migraine. 

The Foundation would also like to see Gepants, a type of calcitonin gene-related peptide inhibitor, to be funded as a different medication option. This is because they have the dual purpose of preventing migraine attacks and they are also a “fantastic” firstline treatment for aborting acute attacks, says Dr Imlach. Gepants are designed to interrupt the migraine process, which reduces the severity and duration of attacks, and also serves as a prophylactic which prevents future attacks. This makes them a suitable alternative for people who cannot take triptans and they are safe for use with chronic migraine.

A study has found that certain gepants can be taken when somebody is experiencing prodrome symptoms and stop the headache phase of their migraine from happening altogether. Dr Imlach says this is “amazing” and it opens up the possibility of having abortive treatments that can effectively stop an attack before it progresses further. 

Pharmac’s Therapeutic Group Manager Logan Heyes confirmed that the agency has received eight applications about four medications that treat episodic or chronic migraine which are currently under review. These are Galcanezumab (Emgality), Atogepant (Equipta), Erenumab (Aimovig), and Fremanezumab (Ajovy). However, Pharmac cannot confirm if or when these medicines will be funded, as this is dependent on budget availability, supplier negotiations, available clinical evidence about treatment benefits, and the prioritisation of funding. 

Heyes said that in 2023, Pharmac’s Neurological Advisory Committee recognised that people with chronic migraine have a higher health need than those with episodic migraine. They also acknowledged an unmet health need for people with migraines generally, due to a lack of migraine specific treatments and limited access to neurology or migraine specialist care within the publicly funded health system. He said the Committee considered that galcanezumab, atogepant, and erenumab could reduce the number of monthly headache or migraine days. This prompted a recommendation that these medicines be funded with a high priority, says Heyes. 

For me personally, the frequency and severity of my migraine disease has increased significantly over a period of less than two years. Completing my Communications degree was challenging, as my brain became more hypersensitive to triggers and debilitating attacks struck me at the most inopportune times.

Living with worsening migraine has cost me opportunities, employment, social connection, or the ability to engage in fulfilling hobbies that bring me joy. My grief is exacerbated by the fact that some of the funded medication options have caused too many side effects or are not suitable for me to trial.

Patients often find themselves limited to trying an off-label medicine in an effort to reduce the number of acute attacks. Dr Imlach says that all of our existing medications for preventing migraine are repurposed drugs which have coincidentally been found to have some usefulness in treating or preventing migraine attacks. 

“But because they weren’t developed to treat migraine, they have all the issues of side effects and not working one hundred percent because they’re not exactly targeting migraine fully,” says Dr Imlach. 

Dr Imlach noted that the side effects from blood pressure hypertensives, antidepressants, or antiepileptics are horrible, which often results in people discontinuing their use because of their “disturbing” effects. Furthermore, these repurposed medicines do not have a particularly high efficacy rate for relieving acute attacks or reducing their frequency in patients. 

New Zealand currently has little data on the economic effects from migraine disease, but some Australian research highlights a significant burden. According to a 2018 Deloitte Access Economics white paper, the total economic cost of migraine in Australia is $35.7 billion each year. This total includes $14.3 billion of health system costs, $16.3 billion of productivity costs, and $5.1 billion of other costs - such as carer support. 

Dr Imlach says that migraine disease has “huge” and extensive costs on a person’s quality of life, their loved ones, and wider society. It is a painful, chronic disease that you will have throughout your life and if you are unable to work to your full potential, then you are going to be disadvantaged. She noted that the effects from migraine are cumulative, with the potential for them to permeate through a person’s employment, finances, self-worth, family, social life, recreation and community participation.  

Therefore, Dr Imlach emphasised the urgency and importance of Pharmac funding a greater range of migraine-specific medications. This would give patients a better toolkit of management options with fewer side effects, which could help to alleviate both their symptoms and emotional distress. She said that it is possible for migraine to be managed well in the community with targeted medications and guidance from primary care doctors. We know that if migraine is treated optimally by effectively relieving acute attacks and taking preventives early, then we reduce the risk of someone progressing into more debilitating chronic migraine, says Dr Imlach.

Weighing up the devastating toll that migraine disease has on my life can be profoundly upsetting. It is gut wrenching knowing that potential relief remains out of reach for many, due to the expenses involved with self-funding these new medicines. Living with migraine is excruciating and the lack of affordable migraine-specific treatments only worsens the suffering.

“Mood disorders are higher in people with migraine and I think that [the lack of affordable migraine-specific medications] will exacerbate it, thinking that I could have a better life but that I can’t afford it. What sort of society do we want to live in that allows that really?,” says Dr Imlach.

Migraine Foundation Aotearoa are optimistic that further consultation about the benefits of these new treatments and the positive improvements on patients’ quality of life will ensure that a more diverse range of migraine medications are funded. 

Dr Fiona Imlach says that she feels migraine has been given very little priority in New Zealand with regard to funding new treatment options or research. [Photo: Dr Fiona Imlach]. 

Migraine disease is excruciating, it has become one of my most disabling illnesses and it significantly affects my quality of life - Melissa Irving. [Photo: Melissa Irving]. 

Content for Visual Pull-Out Box about Migraine Medication Costs:-

Monthly Emgality injections cost approximately $325.00 per 120mg dose. However, patients will need two injections the first time - which doubles the cost. Meanwhile, Aimovig is even more expensive with a 70 mg injection costing $678.00 or $1356.00 for a 140 mg dose.