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Cost-Effectiveness of Erenumab and Surgical Trigger Site Deactivation in the Treatment of Migraine Headaches: A Systematic Review
Nikhil Shah, BS 1, Ruben Castro, MD 2, Sanaz N. Attaripour Isfahani, MD 2, Raj M. Vyas, MD, FACS 2 1Northwestern University Feinberg School of Medicine, Chicago, IL. 2University of California, Irvine School of Medicine, Orange, CA.

Background: Migraine headache is a common, debilitating condition responsible for astronomical societal burden. The chronicity of migraine headaches necessitates the use of many healthcare services. Preventative treatment remains the desirable option for this patient population. Pharmacologic advances have led to the development of erenumab, a monoclonal antibody calcitonin gene-related peptide (CGRP) receptor antagonist that directly interferes with the known biochemical pathway of migraine initiation. Alternatively, surgical decompression of migraine trigger sites is a historically effective preventative option for certain patients experiencing migraine headaches. As new treatments emerge, the large economic burden of migraine headaches require cost evaluation against already available preventative modalities.

Methods: Studies evaluating the cost-effectiveness of both erenumab and surgical trigger site deactivation were found using EMBASE and MedLine. Prospective, retrospective, and modeling paradigm studies were all included. Relevant economic data was extracted from this literature and the cost of treatment with erenumab was compared with surgical decompression.

Results: Direct healthcare utilization costs included acute migraine treatment along with estimated cost of medical services. Speculative models predicted a direct annual healthcare cost ranging from $11,404 to $12,988 for patients experiencing episodic migraine. For chronic migraine patients, this range extended to $25,604. Annual indirect costs, accounting for loss in work productivity, ranged from $7,601 to $19,377. The market price of erenumab is $6,900/year. Prospective and model-based studies evaluating surgical trigger site deactivation reported an average one time surgical cost between $6,956 and $10,303. In episodic migraine, subsequent annual healthcare costs were approximately $900 after both treatments.

Conclusion: This review suggests that the upfront cost of surgical treatment in migraine headaches will be surpassed by the cost of treatment with erenumab after one year (Figure 1). These two treatment options have divergent characteristics - erenumab is a recurring treatment for which we are extrapolating effectiveness beyond the first years, while operative treatment is a more invasive intervention with longer term efficacy data. While surgical resection may be the cost-conscious, proven option, erenumab represents a potentially revolutionary non-invasive treatment option for patients suffering from migraine refractory to other treatments. Not all patients are candidates for deactivation surgery. Moving forward, neurologists and plastic surgeons should collaborate to develop a migraine treatment algorithm that considers both cost and treatment efficacy for their patients.

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