Despite migraine being NZ’s fourth-highest cause of disability, we are lagging behind our OECD partners when it comes to funding new migraine-specific medications – Pharmac is yet to approve any. Dr Fiona Imlach argues it’s time for politicians to realise the full impact of this debilitating condition.
Comment: Inadequate access and funding of medications in Aotearoa New Zealand is a difficult issue for many and has become a painful problem for people with migraine.
Migraine is a complex, disabling neurological condition that has long been ignored and stigmatised, despite affecting an estimated 642,000 people in New Zealand.
This stigma is evident by a lack of research, awareness and knowledge about migraine here, but particularly by a lack of funded medications available in many other OECD countries.
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While Pharmac has medications waiting in the wings to be approved for funding, due to shrinking budgets and longer-than-usual approval times, it could take years before those are rolled out to Kiwis in need.
This election year, politicians should be looking for ways to take the pressure off the health system. One of these ways is to provide fair access to medications that can prevent disability, which means fewer medical consults and visits to ED and less money spent on other treatments.
Funding new preventive medications for migraine is a great example of how this could work.
Migraine is the fourth-highest cause of disability in this country (measured by years lived with disability), equivalent to 24,000 years of healthy life lost in 2019 – comparable to depression.
But unlike depression, migraine has had no national campaigns to raise awareness, reduce stigma and improve treatment rates, which makes access to effective migraine-specific treatment even more important.
This is especially true for those with chronic migraine, which affects an estimated 1-2 percent of the population. People with chronic migraine in New Zealand are less likely to be able to work or can only work part time, have more severe disability and poorer self-rated health. Effective treatment can not only improve quality of life, but also productivity.
Most people with migraine experience occasional attacks, but when they occur on four or more days a month, or attacks are severely disabling, preventive medications are recommended to stop attacks occurring.
Effective preventives, coupled with prompt management of acute attacks, can stop migraine progressing into a chronic form, when people experience headache on 15 days or more per month. But access to effective preventives is where we are getting stuck in New Zealand.
Before 2018, the only medications available to prevent migraine were those developed to treat other conditions, such as depression, epilepsy, high blood pressure or wrinkles (in the case of Botox), but had been found, serendipitously, to have some effect in treating migraine.
But repurposing drugs developed for one disease to a different one isn’t ideal. To treat migraine, you have to take these drugs for months before you know if they might be effective. They don’t always work and they have side effects, so many people stop taking them. From a survey of New Zealanders in 2022, over a quarter of people with chronic migraine were not taking preventive medication.
They had run out of options or weren’t being given appropriate treatment. Others were taking preventives but still had a very high level of disability and very frequent headaches. The drugs weren’t working.
In 2018, medications that blocked a protein in the brain involved in setting off and perpetuating migraine attacks were approved in the US and Europe. They were the first ever developed specifically to prevent migraine and this marked a revolution in its treatment. There are currently eight medications available globally that target this protein, called calcitonin gene-related peptide (CGRP). Six of these are used for prevention and three are used to treat attacks.
Compared to the older preventives, these new medications are safer and more effective. Many are funded in the US, the UK, Australia and Europe.
In New Zealand? Two are available but neither are funded and both are expensive.
One was provisionally recommended for funding by Pharmac but has been held up in the its assessment process for over two years, waiting for review by a specialist committee.
An application for funding the other was submitted in November 2022 and has yet to be reviewed. Pharmac’s website says that in recent years, applications took an average of 15.3 months to be added to one of Pharmac’s ‘priority lists’ but clearly this estimate has a long tail.
The protracted review by Pharmac is one battle to be fought, but even if a medication is approved for funding, a recent report found that they sit on those ‘priority lists’ for an average of nearly six years (and counting).
One reason for this is that the budget for medicines dispensed at community pharmacies, when adjusted for general inflation and population growth, has actually been shrinking, from $605 million in 2011 to $423 million in 2021.
There are many medications that should, and need to be funded in New Zealand. Migraine-specific medications deserve to be added to the list, as they have the potential to reduce the pain and disability of thousands of people living with the condition. It’s unfair that some of these are currently only available to those who can afford to pay for them out of pocket.
All people in New Zealand deserve access to modern medicines so we are on par with countries such as Australia, Canada and the UK.
But the question of whether they get funded comes down to what we value.
In an election year, this is the opportunity to let politicians know what is important to us and what difference it would make if new medicines were a priority – and not left to languish on a Pharmac wish list for years.
Dr Fiona Imlach is a senior research fellow in the Department of Public Health at the University of Otago, Wellington. She is also cofounder of Migraine Foundation Aotearoa New Zealand.
