BACKGROUND: Chronic migraines affect approximately 2 percent of the U.S. 
population and cost an estimated $17 billion per year. OnabotulinumtoxinA 
(botulinum toxin type A) is a U.S. Food and Drug Administration-approved 
prophylactic medication for chronic migraine headaches and is best injected in a 
targeted fashion into specific trigger sites. The purpose of this study was to 
determine the cost-effectiveness of long-term, targeted botulinum toxin type A 
versus peripheral trigger site deactivation surgery for the treatment of 
migraine headaches.
METHODS: A Markov model was constructed to examine long-term, targeted botulinum 
toxin type A versus peripheral trigger site deactivation surgery. Costs, 
utilities, and other model inputs were identified from the literature. One-way 
and probabilistic sensitivity analyses were performed. An incremental 
cost-effectiveness ratio under $50,000 per quality-adjusted life-year was 
considered cost-effective.
RESULTS: The mean cost of peripheral trigger site deactivation surgery was 
$10,303, with an effectiveness of 7.06; whereas the mean cost of long-term, 
targeted botulinum toxin type A was $36,071, with an effectiveness of 6.34. 
Trigger-site deactivation surgery is more effective and less costly over the 
time horizon of the model. One-way sensitivity analysis revealed that surgery is 
the most cost-effective treatment in patients requiring treatment for greater 
than 6.75 years.
CONCLUSIONS: Based on this model, peripheral trigger site deactivation surgery 
is the more cost-effective option for treating refractory migraine headaches 
requiring treatment beyond 6.75 years. The model reveals that peripheral 
trigger-site deactivation surgery is more effective and less costly than 
long-term, targeted botulinum toxin type A over the course of a patient's 
lifetime.