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I wish that I was coming here to announce some major breakthrough in headache treatment. The advances are far too slow for all of us. I will be attending the International Congress on Migraine and Headache next week in Glasgow. It is where all the scientists and thinkers as well as hundreds of headache clinicians meet to discuss the latest findings and treatments. I will try to post any new things here or at least on our Face Book page.

The Demise of Botox?

I  know that I often sound like a broken record, complaining about the decline in headache medicine, but is true. There are fewer and fewer headache clinics and there were not enough to start with.  The noose around the necks of headache care is tightening and there has never been such a gap between what we could do for a patient and what can do as there is now. The difference is between knowing how to treat something and having the opportunity to provide that care.  There are several factors that are contributing to that including; 1)  insurance companies trying very hard to protect their income in the post-ACA (Obamacare) world and headache sufferers are an easy target, 2) pharmaceutical companies gouging patients because there is no limit on what they can charge in America and it is not a free market that would have self-limiting influences (e.g. a competitive market where the lowest priced drug wins),  and 3) cultural mores that put barriers on patients getting good care.

Botox is becoming a prime example of this story. It does work, at least in chronic migraine. It is not a panacea as over 40% of patients see no benefit. But it is one tool of many tools. While Allergan is continue to promote Botox for chronic migraine prevention to the public, the insurance companies are now tightening the noose around our use of it.

In the beginning, besides the fact that it works for many patients, doing Botox helped the headache clinics. Allergan charges about $1200 for a vial of Botox and the practitioner could get paid  as much as $1400 per vial plus payment for his or her time. That has gradually changed where the insurance companies paid, at most, the actual cost of Botox, but often paid the practice below cost (e.g. $1100) or often, would not pay for the Botox at all, giving the clinic a big loss. This hurt a lot of small practices, some headache clinics went bankrupt over this plus other actions of insurance companies. I can say with confidence if Pacific Rim Headache Clinic had never done Botox for our patients, we would still be in business today.

Most small practices stopped buying Botox because of the losses, but kept doing it for the sake of the patient. The insurance companies have made it more and more difficult to get covered. So, one prior authorization would take up to six man hours. This including the provider’s time and the office staff time. It then became a sum loss to do Botox because the cost of the prior auth was far greater than the $200 paid for the treatment.

Practices continued doing Botox because it was helping our patients, even though it was a sum loss in revenue.

Now, enter 2016. The insurance companies have tightened the screws even more. Besides having to jump through all the hoops to get the Botox approved, they are now requiring a new approval for each treatment. The new approvals are somewhat of a “Catch 22.”  If the Botox works and the patient’s headaches get better (below 15 days per month) the insurance companies will deny further treatments because the patient no longer meets the criteria of having 15 days per month of headaches. If the Botox doesn’t work significantly, where the patient is using less triptans and ED visits (thus saving the insurance money in the long run) they will deny future treatments.  Regardless, they require even more paper work for each treatment. Now, the average treatment cost a practice about $500 for the behind-the-scenes paper work and at best, they are getting reimbursed about half that.

So in ten years small practices went from making $500 per treatment to loosing almost that much. It no longer makes business sense for headache clinics to continue doing Botox. The only reason we are still doing it is for the sake of our patients. There is nothing more the insurance companies would want than them to say they “offer Botox to their subscribers” but make it impossible for the clinics to use it.

What is a patient to do? I just want them to be aware of the situation. Patients only see the tip of the iceberg of our constant fighting with their insurance companies. Please be patient with Sue (our Botox prior auth person) and others who are working on their behalf. It is a convoluted mess and it makes us all look like fools trying to navigate it, and I think that is the purpose of the labyrinth. We only do this because we care about our patients.


I have spoken hear several times about the Spring TMS (Trans-cranial Magnetic Stimulator) as a promising non-pharmacological  treatment to prevent and treat developing (abort) migraines. It is not perfect as I am sure it will fail for many patients, but it also seems to work well for many.

I have over ten patients using the device now and most are doing better. The biggest downside is it cost $400 to lease it for the first three months from the company that makes it. I was doubtful that insurance companies would pay for it because 1) it is modestly expensive and 2) it is for headache, which, from their perspective, doesn’t seem to matter.

Recently I prescribed the device for a patient. It was rejected by the insurance, which was to be expected. Then I wrote a letter to appeal. The appeal was then rejected when they had a “peer” review the case and say it was not needed.

I was about to let this go until I read the letter from the insurance company. It was appalling. First their “Peer” or headache expert was a cancer doctor. He, from his gross misunderstanding of the device, had probably never head of it before.  He then said there were no supporting studies (to date there have been six) and it was not FDA approved for migraine (I have the letter from the FDA approving it for migraines).

I took about six hours of my time, out of pure protest of an injustice, to write a response to them. I scolded them for calling a cancer doctor a headache expert. I also demanded that they only use headache specialists to review such cases and that they have a headache specialist write their policies.

This injustice for headache sufferers must stop. Once again I ask patients to write their benefits mangers and insurance companies, congressmen/women and others to demand that board certified headache specialists write and review policies for insurance companies. They will mislead you and say of course they do. But what they call a headache specialist is any physician to whom they have assigned that title. I know of no insurance company that acknowledges the field of Headache Medicine, the millions of sufferers or headache specialists who treat them. It is time for this behavior to end.

So this concerns me because we have a whole new generation of exciting, effective and safe treatments coming for headache disorders (as soon as 2017). However, this will be a moot point if the insurance companies reject all of them (because they don’t have anyone within their companies who understand them).

I will keep you informed of anything new and exciting from Glasgow.

Mike  Jones