Clinical Guidance Library
PA Guidance Library
Twenty clinical guidance cards for headache care in primary care — covering PA mechanics, treatment evidence, coding, and the documentation language that determines whether a prior authorization is approved or denied.
Run a PA — free →PA Mechanics
The rules of the PA system — what payers require, how to document it, and where submissions fail.
CGRP-targeted preventives require documented failure of two oral preventive classes — here is what payers actually look for.
MOH develops when acute medications are used too frequently — documenting it strengthens any CGRP PA submission.
The episodic/chronic distinction determines which treatments qualify, which ICD-10 codes apply, and which denial pathways will be used against you.
Step therapy denial is the most common preventable PA failure — reviewers need four data points per trial: agent, dose achieved, duration, and reason for stopping.
Migraine with aura plus combined hormonal contraceptives multiplies stroke risk approximately four to eight times — WHO Category 4 requires switching to progestin-only or non-hormonal methods.
Biofeedback, CBT, and relaxation training have Level A evidence — document them as complementary therapy, not primary, to avoid weakening your PA.
Gepant PAs require documented triptan failure or a specific contraindication — document each trial with agent, dose, timing, and outcome.
Three CGRP mAbs have FDA pediatric approval — step therapy is reduced but not eliminated, and teratogenicity bypass is stronger for adolescents than adults.
Botox requires G43.7xx, PREEMPT protocol documentation, and two oral preventive failures — submitting under an episodic code produces automatic denial.
Clinical Practice
Diagnosis, coding, referral, and emergency management with direct PA consequences.
Cluster headache is not migraine — PA pathway, ICD-10 codes, oxygen as a DME benefit, and acute treatment are entirely different.
Most migraine patients don't need a specialist — but when they do, start preventive therapy now rather than waiting six months for the appointment.
An ER visit is documented evidence of outpatient treatment failure — use it in PA language, build a rescue plan, and close the loop within one week.
G44.52 produces automatic PA denial for CGRP mAbs and Botox — if the patient has a prior migraine history, correct the code to G43.7xx before submitting.
Copy-paste EHR templates generate PA-supporting documentation as a byproduct of routine clinical notes — available for every major headache documentation scenario.
Clinical Context
The science behind treatment decisions — and how to document it in the PA narrative.
Many reported 'triggers' are prodromal symptoms — reframe them as treatment windows, and document the distinction to strengthen the PA narrative.
Standard 9-dose quantity limits force patients to ration acute medication — document the rationing behavior, the central sensitization consequences, and the ER visit history to support quantity override appeals.
The 83% conversion gap starts in the exam room — navigate the five most common patient objections to migraine medication, and document each conversation to protect the PA narrative.
Medical education allocates four hours to headache disorders. This card covers the minimum pathophysiology that changes how you document, prescribe, and file prior authorizations — science with direct operational consequences.
Instruments
Validated tools and devices: what they measure, how to administer them, and how scores appear in PA submissions.
Four FDA-cleared neuromodulation devices are available for migraine — two without a prescription. Document patient device use before filing a PA: it satisfies non-pharmacological step therapy requirements and strengthens the clinical narrative.
MIDAS counts lost days; HIT-6 measures impact. Both take under two minutes chairside and function as objective anchors in PA submissions, referral letters, and specialist communication — more defensible than narrative self-assessment.