Clinical Policy Bulletin: Migraine and Cluster Headache: Nonsurgical Management

Policy Aetna considers parenteral administration of dihydroergotamine (DHE) medically necessary for the treatment of intractable migraine or cluster headache. Prolonged multi-day administration of DHE is considered medically necessary when both of the following conditions are met: 1. Member has intractable cluster headache or severe migraine headache (i.e., status migrainosus, chronic daily headache, transformed migraine, rebound headache); and 2. Headache is refractory to maximum outpatient anti-migraine therapy. Aetna considers parenteral DHE experimental and investigational for all other types of headache due to insufficient evidence in the peer-reviewed literature. Aetna considers measurement of serum and/or cerebrospinal fluid levels of tumor necrosis factor-alpha experimental and investigational for intractable migraine or cluster headache due to insufficient evidence in the peer-reviewed literature. Aetna considers the following interventions experimental and investigational for the management of members with migraines due to insufficient evidence in the peer-reviewed literature (not an all-inclusive list): Cefaly migraine headband Intranasal ketamine Intranasal lidocaine Intrathecal dilaudid or hydromorphone Intravenous aspirin (lysine acetylsalicylate) Intravenous ketamine Intravenous lidocaine Intravenous magnesium Intravenous methylprednisolone or other steroids Intravenous nalbuphine or other opioid agonist-antagonists Intravenous valproic acid (Depacon) Lidocaine injections into the supraorbital nerve and supratrochlear nerve, supraorbital nerve and supratrochlear nerve blocks Orally inhaled DHE Melantonin (for prophylaxis of migraine) Obesity surgery Supraorbital transcutaneous stimulation (for migraines and other types of headaches) Transcranial magnetic stimulation (e.g., SpringTMS) Aetna considers sodium oxybate for the treatment of cluster headache experimental and investigational due to insufficient evidence in the peer-reviewed literature. Aetna considers the Reed procedure (combined occipital and supraorbital neurostimulation) experimental and investigational for the treatment of chronic headaches because its effectiveness has not been established.