A systematic review of economic evaluations of pharmacological interventions for adults with episodic migraine

Abstract Background and aims Episodic migraine is an increasingly common disorder with considerable associated economic costs. We undertook a systematic review to identify and synthesize full economic evaluations of preventative pharmacological treatments for episodic migraine. Methods We used search terms for migraine/headaches and pharmacological interventions combined with relevant economic terms. Our key inclusion criteria were studies undertaking full economic evaluation that presented costs and outcomes, by treatment arm. We included studies of adults with episodic migraine (< 15 days per month), comparing prophylactic with any comparator, including placebo, usual care, or other prophylactic drugs. Outcomes included monthly migraine days, monthly headache days, headache related disability and health economic measures (including incremental cost-effectiveness ratios). We assessed abstracts and citations, with subsequent full text article review. A comprehensive review of study characteristics, methodology and reporting was undertaken, with quality assessed against established checklists. Results We conducted searches in October 2025 and updated in February 2026. Fifteen citations met the inclusion criteria and were cost-effectiveness or cost-utility studies evaluating Atogepant ( n = 3), Eptinezumab ( n = 1), Erenumab ( n = 4), Fremanezumab ( n = 1), Gabapentin ( n = 1), Galcanezumab ( n = 1), Propranolol ( n = 1), Rimegepant ( n = 2) and Topiramate ( n = 2) as the intervention. Studies were conducted in six countries and over a 23-year period. There was wide variation in results: Erenumab was cost-effective in two of three studies; Eptinezumab was dominant compared to best supportive care; Fremanezumab was cost-effective in a single study, and Atogepant was not cost-effective. Technical reports of Erenumab, Galcanezumab and Atogepant showed they were cost-effective for those who have failed three prior preventative drug treatments. Most studies performed sensitivity analyses to understand the robustness of results. No studies met all the criteria of the CHEERS reporting checklist for economic evaluations or the Philips’ checklist for economic models. Conclusions We synthesised evidence on the cost-effectiveness of pharmacological treatments of episodic migraine in adults. Based on the findings from technical reports Erenumab, Galcanezumab and Atogepant were cost-effective in patients with previous treatment failures. Journal articles reported Eptinezumab and Fremanezumab to be cost-effective versus best supportive care/placebo. Additional research is required to determine optimal decision making for the preventative treatment of episodic migraine. PROSPERO registration CRD420251233775. Clinical trial number Not applicable.