The Acute Treatment Ladder — Getting the Step Therapy Right Before You Submit
Gepant PAs require documented triptan failure or a specific contraindication — document each trial with agent, dose, timing, and outcome.
PA impact: This card directly affects prior authorization outcomes. Documentation language from this card can be used in PA letters and appeals.
Start with triptans. For moderate-to-severe migraine attacks, triptans are appropriate first-line prescription acute treatment — and for PA purposes, the gate that must be documented as passed before most payers approve a gepant. Most payers require failure of two triptans before approving ubrogepant, rimegepant, or lasmiditan. Document each triptan trial with: agent, dose, timing relative to attack onset, number of attacks treated, and specific outcome including reason for switching.
When to skip triptans entirely. Three documented situations bypass triptan step therapy at virtually all payers. First, cardiovascular contraindications — triptans are vasoconstrictors, and any patient with CAD, peripheral vascular disease, uncontrolled hypertension, or stroke history has an absolute contraindication. Second, serotonin syndrome risk — patients on MAOIs cannot use triptans. Third, hemiplegic migraine or migraine with brainstem aura — triptans are FDA-contraindicated for these subtypes regardless of cardiovascular status. Document the specific contraindication in the chart, not just "triptan contraindicated."
Where gepants and ditans fit. Gepants (ubrogepant, rimegepant, zavegepant) and lasmiditan (Reyvow) occupy the next rung after triptan failure or contraindication. They do not cause vasoconstriction and carry lower medication overuse risk than triptans, making them appropriate for patients with cardiovascular contraindications, high-frequency attacks where MOH is a concern, or documented triptan intolerance. The PA for gepants/ditans needs triptan step therapy documented or bypassed — not assumed.
Quantity limits and early treatment. Standard payer quantity limits of 9 triptans per month are clinically insufficient for patients with more than 9 headache days. Patients forced to ration acute medication delay treatment, which reduces effectiveness and promotes central sensitization (see Card 16). When documenting acute treatment response for PA purposes, note whether the patient had adequate medication supply to treat all qualifying attacks. A Visit Ready Report showing 15 headache days with 9 treated days demonstrates both treatment efficacy and the need for increased supply.
Treatment response ambiguity. Before documenting a triptan trial as "failed," clarify what happened. Expected triptan sensations (chest tightness, jaw pressure, fatigue, tingling) are often mistaken for adverse reactions by patients who weren't warned about them. One undertreated attack doesn't constitute a failed trial. An adequate triptan trial means correct dose, correct timing (early in the attack), correct formulation, and at least three attempts. Document the specifics — a well-documented genuine failure strengthens the PA, while a vague "didn't tolerate" can be challenged on review. (See Card 16 for the non-refill problem and clinical intervention.)
Ready to run a PA?
The PA Engine applies this guidance automatically — paste a clinical note and get a complete, payer-specific PA letter in under a minute. Free, no account required.
Run a PA — free →Citations: AHS Consensus 2021 — Ailani J et al., Headache 2021;61(7):1021-1039. doi:10.1111/head.14153 | FDA Drug Safety Communication: serotonin syndrome with triptans and serotonergic drugs (2010) | FDA prescribing information: ubrogepant, rimegepant, zavegepant, lasmiditan.