The recent publication of drug formularies by third-party payers has serious implications for the practice of medicine. These formularies list the medications for which the consumer can be reimbursed by the third-party payer. The most restrictive of the five formularies I have received lists only two agents for the treatment of
migraine headaches:
Cafergot (at an incorrect dose of 1/100 mg) and
Ergotrate which is no longer available. The most liberal of the formularies lists
analgesics,
Cafergot,
Midrin, and Imitrex for the treatment of acute attacks, and as prophylactic agents,
Inderal,
Sansert, and
analgesics (known to cause rebound
headaches when used in this fashion in
migraine patients). Abortive agents of proven value, such as
DHE-45 and
NSAIDs, and preventative medications, such as
calcium channel blockers,
tricyclic antidepressants,
serotonin reuptake inhibitors,
methylergonovine, and
divalproex sodium, are not available. No one could quarrel with a goal of developing a cost-effective formulary. However, the authors of these formularies have clearly demonstrated their inability to provide even a current, accurate, and adequate formulary by existent standards of care in the treatment of
migraine headache. While it is easy to criticize these formularies, it is more difficult to develop a comprehensive list that would satisfy the practitioners' need to provide relief for their patients with a minimum of side effects, and the needs of third-party payers (presumed) to provide quality care at the most economical level.