Anthem Blue Cross California Dihydroergotamine (DHE) Injection Form

Overview

This document addresses the use of dihydroergotamine (DHE) injection. DHE is approved for the subcutaneous, intravenous or intramuscular treatment of acute migraine headaches with or without aura and the acute treatment of cluster headache episodes. DHE has a black box warning regarding serious and/or life-threatening peripheral ischemia if co-administered with a potent CYP3A4 inhibitor, including protease inhibitors and macrolide antibiotics. Concomitant use is contraindicated.

Clinical Criteria

When a drug is being reviewed for coverage under a member’s medical benefit plan or is otherwise subject to clinical review (including prior authorization), the following criteria will be used to determine whether the drug meets any applicable medical necessity requirements for the intended/prescribed purpose.

Dihydroergotamine (DHE) Injection

Requests for intravenous, intramuscular or subcutaneous dihydroergotamine (DHE) injection may be approved if the following criteria are met:

1. Individual is age 18 or older; AND
2. Individual is using for acute treatment of migraine with aura; AND
3. Individual meets the following International Headache Society (IHS) diagnostic criteria (ICHD-3):
   • A. Individual has 2 or more headache attacks; AND
   • B. Individual has 1 or more of the following fully reversible aura symptoms:
     1. Visual (for example, flickering lights, spots or lines); OR
     2. Sensory (for example, pins and needles, numbness); OR
     3. Speech and/or language (for example, aphasia); OR
     4. Motor (for example, weakness); OR
     5. Brainstem (for example, ataxia or vertigo); OR
     6. Retinal (for example, blindness); AND
   • C. Individual has at least three of the following six characteristics:
     1. At least 1 aura symptom develops gradually over 5 or more minutes; OR
     2. Two (2) or more aura symptoms occur in succession; OR
     3. Each individual aura symptom lasts 5 to 60 minutes; OR
     4. At least 1 aura symptom is unilateral; OR
     5. At least one aura symptom is positive (scintillations and pins and needles are examples of positive symptoms of aura); OR
     6. The aura is accompanied, or followed within 60 minutes, by headache; AND
   • D. Individual’s headache is not attributed to another disorder (for example, ischemia stroke or transient ischemic attack); OR
4. Individual is age 18 or older; AND
5. Individual is using for acute treatment of migraine without aura meeting the following IHS diagnostic criteria (ICHD-3):
   • A. Individual has 5 or more headache attacks; AND
   • B. Individual’s headaches last 4 to72 hours (untreated or unsuccessfully treated); AND
   • C. Individual’s headache has 2 or more of the following characteristics:
     1. Unilateral location; OR
     2. Pulsating quality; OR
     3. Moderate or severe pain intensity; OR
   • D. Aggravation by or causing avoidance of routine physical activity (for example, walking or climbing stairs); AND
   • E. Individual’s headache is accompanied by 1 or more of the following:
     1. Nausea, vomiting or both; OR
     2. Photophobia or phonophobia; AND
   • F. Individual’s headache is not attributed to another headache disorder; OR
6. Individual is age 18 or older; AND
7. Individual is using for acute treatment of cluster headache episodes meeting the following IHS diagnostic criteria (ICHD-3):
   • A. Individual has 5 or more headache attacks; AND
   • B. Individual has severe or very severe unilateral orbital, supraorbital and/or temporal pain lasting 15 to 180 minutes if untreated; AND
   • C. Individual’s headache is accompanied by 1 or both of the following:

2. 1 or more of the following symptoms or signs, ipsilateral to the headache:
   • a. Conjunctival injection and/or lacrimation; OR
   • b. Nasal congestion and/or rhinorrhea; OR
   • c. Eyelid edema; OR
   • d. Forehead and facial sweating; OR
   • e. Miosis and/or ptosis; OR
3. A sense of restlessness or agitation; AND
4. D. Attacks have a frequency from 1 every other day to 8 per day for more than half of the time the disorder is active; and
5. E. Individual’s headache is not attributed to another headache disorder. OR

VIII. Individual has status migrainosis or rebound withdrawal type of headaches.

Requests for intravenous, intramuscular or subcutaneous dihydroergotamine (DHE) injection may not be approved if the following criteria met:

1. Individual is using concomitantly with a potent CYP3A4 inhibitor (including ritonavir, nelfinavir, idinavir, erythromycin, clarithromycin, troleandomycin, ketoconazole, itraconazole); OR
2. Individual has a diagnosis of ischemic heart disease (angina pectoris, history of myocardial infarction, documented silent ischemia) or has clinical symptoms consistent with coronary artery vasospasm including Prinzmetal’s variant angina; OR
3. Individual has uncontrolled hypertension; OR
4. Individual has hemiplegic or basilar migraine; OR
5. Individual has used a 5-HT1 agonist (such as sumatriptan), ergotamine-containing or ergot-type medication or methysergide within the previous 24 hours; OR
6. Individual has peripheral arterial disease; OR
7. Individual has severely impaired hepatic or renal function.

Coding

The following codes for treatments and procedures applicable to this document are included below for informational purposes. Inclusion or exclusion of a procedure, diagnosis or device code(s) does not constitute or imply member coverage or provider reimbursement policy. Please refer to the member's contract benefits in effect at the time of service to determine coverage or non-coverage of these services as it applies to an individual member.

HCPCS

• J1110 Injection, dihydroergotamine mesylate, per 1 mg

ICD-10 Diagnosis

• G43.001-G43.919 Migraine
• G44.001-G44.029 Cluster headaches
• G44.40-G44.41 Drug-induced headache not elsewhere classified

Document History

Revised: 05/19/2023