Central Nervous System
Pain management

Diagnosis: Migraines
Treatment: Pain management
The insurer denied Intravenous Ketamine Infusion(s.)
The health plan's determination is upheld.

The patient is a female diagnosed with CADASIL (Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy) and chronic migraines. The patient has tried and failed various treatments for prevention of chronic migraine. These include anticonvulsants, antidepressants, beta-blockers, and Botox.

Intravenous Ketamine Infusion(s) are not medically necessary for this patient.
Treatment of chronic migraine with intravenous ketamine is not indicated. Controlled studies are lacking to show that this drug is safe and effective for treatment of chronic migraine. There is a paucity of peer-reviewed literature. One case series in which patients with chronic migraine were treated with intravenous ketamine infusion found that the treatment lead to "short term improvement in pain severity." This study called for placebo controlled trials. Another study that examines the use of ketamine infusions for chronic migraine and new persistent daily headache found that "ketamine infusions may be beneficial" and called for controlled trials to confirm this. Another study looked at the administration of ketamine in the emergency room for headache and found that it did not improve headache outcomes. Overall, high quality data is lacking to support ketamine infusions for migraine.