Cost-effectiveness of onabotulinumtoxinA versus topiramate in chronic migraine in the US: an economic analysis of the FORWARD randomized trial

AIMS: Assess the cost-effectiveness of onabotulinumtoxinA (OnabotA) versus topiramate for the preventive treatment of chronic migraine in US adult patients from a payer perspective. METHODS: A multistate Markov model evaluated the incremental costs per headache-day avoided and quality adjusted life-year (QALY) over a 2-year period in patients treated with OnabotA versus topiramate. The FORWARD trial data informed model inputs, including reductions in headache-days, while patients receive OnabotA/topiramate. Treatment discontinuation for topiramate was modeled with data from FORWARD and a randomized controlled trial (RCT) to test a range of values for topiramate. Costs of drug acquisition, administration, and monitoring were calculated from prescribing information and physician fee schedules. The model estimated costs of healthcare resource utilization (HCRU) and acute migraine treatment by response level. Sensitivity and scenario analyses explored cost drivers and assessed model robustness. RESULTS: Our model estimated that OnabotA-treated patients experience 122.56 fewer headache-days (0.34 years) than topiramate-treated patients over the 2-year time horizon. With an incremental cost of $4,639, the incremental cost per headache-day avoided was ∼ $37.85/day, and the incremental cost per QALY gained was $63,646. The estimated cost per avoided headache-day was less than half for patients treated with OnabotA in comparison with topiramate ($116 vs. $246). Sensitivity analyses showed that the incremental cost per headache-day avoided remained below $50 and the incremental cost per QALY gained remained below $100,000 across all tested ranges. Results were similar when using a lower, RCT-supported discontinuation rate for topiramate. In scenario analyses, a longer time horizon and a greater price discount for OnabotA substantially reduced the incremental cost-effectiveness ratios. CONCLUSION: OnabotA was a cost-effective preventive treatment of chronic migraine versus topiramate. Although OnabotA had higher drug acquisition costs, these were offset by reduced HCRU costs due to fewer migraines, resulting in a low incremental cost per headache-day avoided versus topiramate.