Pharmacy Prior Authorization Criteria

Ergot Alkaloids

Indications for Prior Authorization

D.H.E. 45 (dihydroergotamine mesylate) injection

• For diagnosis of Migraine
  Indicated for the acute treatment of migraine headaches with or without aura.

• For diagnosis of Cluster Headache
  Indicated for the acute treatment of cluster headache episodes.

Cafergot (ergotamine tartrate and caffeine) tablet

• For diagnosis of Headache
  Indicated as therapy to abort or prevent vascular headache, e.g., migraine, migraine variants, or so-called “histaminic cephalalgia”.

Criteria

Generic ergotamine tartrate/caffeine tablet, Generic dihydroergotamine mesylate injection

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Migraines

• Diagnosis of migraine headaches with or without aura
AND
• Will be used for the acute treatment of migraine
AND
• Patient is 18 years of age or older [A]
AND
• One of the following: [3]
• Trial and failure or intolerance to two triptans (e.g., eletriptan, rizatriptan, sumatriptan)
• Contraindication to all triptans
AND
• If patient has 4 or more headache days per month, one of the following [B, 4]
• Patient must be currently treated with ONE preventive treatment for migraine from the following:
• Elavil [amitriptyline]
• Effexor [venlafaxine]
• Depakote/Depakote ER [divalproex sodium]
• Topamax [topiramate]
• Atenolol, propranolol, nadolol, timolol, or metoprolol
• Lisinopril
• Aimovig [erenumab-aooe], Ajovy [fremanezumab-vfrm], Vyepti [eptinezumab-jjmr]; Qulipta [atogepant], Emgality [galcanezumab-gnlm], or Nurtec ODT [rimegepant]
OR
• Patient has a history of failure (after at least a two month trial), contraindication or intolerance to ONE preventative treatment for migraine from the following:
• Elavil [amitriptyline] or Effexor [venlafaxine]
• Depakote/Depakote ER [divalproex sodium] or Topamax [topiramate]
• Atenolol, propranolol, nadolol, timolol, or metoprolol
• Lisinopril
• Aimovig [erenumab-aooe], Ajovy [fremanezumab-vfrm], Vyepti [eptinezumab-jjmr]; Qulipta [atogepant], or Emgality [galcanezumab-gnlm]

Generic ergotamine tartrate/caffeine tablet, Generic dihydroergotamine mesylate injection

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Migraines

• Patient has experienced a positive response to therapy (e.g., reduction in pain, photophobia, phonophobia, nausea)

Generic ergotamine tartrate/caffeine tablet, Generic dihydroergotamine mesylate injection

Prior Authorization (Initial Authorization)

Length of Approval: 3 Month(s)
For diagnosis of Cluster Headaches

• Diagnosis of cluster headache
AND
• Patient is 18 years of age or older [A]
AND
• Trial and failure, contraindication, or intolerance to sumatriptan injection [5]

Generic ergotamine tartrate/caffeine tablet, Generic dihydroergotamine mesylate injection

Prior Authorization (Reauthorization)

Length of Approval: 12 Month(s)
For diagnosis of Cluster Headaches

• Patient has experienced a positive response to therapy (e.g., reduction in headache frequency and/or intensity)

P & T Revisions

1970-01-01, 2026-07-17, 2025-12-18, 2025-12-18, 2025-09-25, 2025-03-03, 2024-06-05, 2024-04-03, 2023-04-05, 2022-04-06, 2021-11-16, 2021-06-02, 2021-03-31, 2020-12-02, 2020-04-01

References

1. D.H.E. 45 Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. April 2022.
2. Migranal Prescribing Information. Bausch Health US, LLC. Bridgewater, NJ. September 2022.
3. AHS Consensus Statement. Update on integrating new migraine treatments into clinical practice. Headache. 2021 Jul;61(7):1021-1039.
4. Simpson DM, Hallett M, Ashman EJ, et al. Practice guideline update summary: Botulinum neurotoxin for the treatment of blepharospasm, cervical dystonia, adult spasticity, and headache: Report of the Guideline Development Subcommittee of the American Academy of Neurology. Neurology. 2016 May 10;86(19):1818-26.
5. Robbins MS, Starling AJ, Pringsheim TM, et al. Treatment of Cluster Headache: The American Headache Society Evidence-Based Guidelines. Headache. 2016 Jul;56(7):1093-106.
6. Cafergot Prescribing Information. Sandoz Inc. Princeton, NJ. May 2018
7. Ergomar Prescribing Information. TerSera Therapeutics LLC. Deerfield, IL. February 2020.
8. Migergot Prescribing Information. Cosette Pharmaceuticals, Inc.. South Plainfield, NJ. June 2020.
9. Trudhesa Prescribing Information. Impel Pharmaceuticals Inc. Seattle, WA. August 2023.
10. Brekiya Prescribing Information. Amneal Pharmaceuticals LLC. Bridgewater, NJ. May 2025.

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End Notes

1. The safety and effectiveness in pediatric patients has not been established. [1, 2]
2. The American Academy of Neurology supports the use of the following medications for the prevention of episodic migraine in adult patients (with level A or B evidence): antidepressants [i.e., Elavil (amitriptyline), Effexor (venlafaxine)], antiepileptics [i.e., Depakote/Depakote ER (divalproex sodium), Topamax (topiramate)], beta-blockers [i.e., atenolol, propranolol, nadolol, timolol, metoprolol], and candesartan. [3, 4]

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Revision History

• 2026-07-17: New standalone EHB guideline that contains formulary products only.
• 2025-12-18: No criteria change, bulk copy oRX-EHB
• 2025-12-18: no criteria changes, added IL statute operational note
• 2025-09-25: Addition of Brekiya (dihydroergotamine mesylate) injection to guideline.
• 2025-03-03: 2025 Annual review. No criteria changes.
• 2024-06-05: Removed prescriber requirement and updated background.
• 2024-04-03: Annual review: Updated criteria and background.
• 2023-04-05: Annual review: Updated migraine criteria and background.
• 2022-04-06: Annual review: Background updates.
• 2021-11-16: Added Trudhesa to the guideline and updated initial authorization criteria for migraine.
• 2021-06-02: Added Erogmar, Migergot, and Brand/Generic Cafergot to guideline and updated guideline name.
• 2021-03-31: Annual review: Background updates.
• 2020-12-02: Updated prescriber specialist criteria
• 2020-04-01: New program.

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