The Headache Vault Research Series

CMS Medicare Part D · 2022–2023

The Primary Care CGRP Gap: A National Analysis

An estimated 8,106,059 patients are not receiving guideline-appropriate preventive migraine care from their primary care provider

Doty A. · June 2026 · CMS Medicare Part D 2022–2023

Data scope: Medicare patients only. Source: CMS Medicare Part D Prescriber Public Use Files. True national gap likely larger — commercial claims data not publicly available

What we measured

Methodology

We analyzed CMS Medicare Part D Prescriber Public Use Files — the only publicly available dataset that links individual physicians to specific medications at the national level. We identified 17,284 primary care physicians (Family Practice, Internal Medicine, and General Practice) who wrote 20 or more triptan prescriptions to Medicare patients in the observation period, indicating an active migraine patient panel.

Among those physicians, we found that 15,624 — 90.4% — had never written a single CGRP-targeting therapy prescription to any Medicare patient. The class includes four monoclonal antibodies and two small-molecule receptor antagonists with preventive indications (rimegepant, atogepant); acute-only gepants without preventive approval were excluded. These therapies have been FDA-approved for migraine prevention since 2018. The 2024 American Headache Society consensus statement endorses them as a first-line preventive option; the 2025 American College of Physicians guideline recommends non-specific agents as initial therapy based on cost-effectiveness analysis. The geographic uniformity of the gap — consistent across states with different payer environments and specialist supply — is more consistent with prior authorization burden than with either guideline as the primary driver.

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Notable findings

Best state, worst state, notable metros.

Why the gap exists

Prior authorization as the primary barrier.

Prior authorization is the dominant structural barrier. CGRP-targeting therapies require prior authorization from the majority of commercial and Medicare Advantage insurers. The average PA takes 15–45 minutes of staff time per submission, with denial rates of 20–40% on first attempt. Primary care practices without dedicated PA staff face a straightforward calculation: the administrative cost of attempting a CGRP PA exceeds the time available.

This is not a knowledge gap. The PCPs in this analysis are actively prescribing triptans — they are engaged with migraine care and familiar with the treatment landscape. The gap is between what they know is available and what they can practically prescribe given the administrative environment. The Headache Vault PA Engine was built to eliminate this barrier.

State Pages

State-by-state analysis

Individual state reports for all 50 states. Each includes active prescriber counts, metropolitan area breakdowns, patient harm estimates, and a citable citation block.

States with fewer than 100 active prescribers in the Medicare dataset are excluded from state-level reporting (small-sample suppression).

Citation format: Doty A. Migraine Prescribing Gap in [State]. The Headache Vault; June 2026.

For individual state reports, cite as: Doty A. Migraine Prescribing Gap in [State]. The Headache Vault; June 2026. with the stable URL for that state page.