Cost-Utility Analysis of Surgical Decompression Relative to Injection Therapy for Chronic Migraine Headaches

Goals/Purpose: Common treatment for chronic migraine headaches include injection of corticosteroid and anesthetic agents at local trigger sites. However, the effects of therapy are short-term and lifelong treatment is often necessary. In contrast, surgical decompression of migraine trigger sites accomplishes the same goal yet demonstrates successful long-term prevention of chronic migraines. In addition to cost considerations, patients and physicians must discuss quality of life implications of various treatment options. These include characteristics of treatment such as the probability of a successful outcome, adverse events associated with treatment, contraindications, duration of treatment, inpatient and outpatient visits, and overall changes in quality of life before and after treatment. Therefore, analysis is necessary to determine the complex interplay between the quality of life conferred to patients and cost of the available treatment options for chronic migraine disorders. As such, our primary objective was to perform a cost-utility analysis to determine which patients would benefit most from available treatment options in a cost-conscious model.

Methods/Technique: A cost-utility analysis was performed in consideration of costs, probabilities, and health state utility scores of the opposing interventions. Amazon Mechanical Turk© crowdsourcing was used to derive utility scores associated with surgical decompression and injection therapy. A systematic review was also performed to identify common complications of treatment and their associated probabilities. Direct costs were derived from national Medicare facility reimbursement data and outpatient care billing data for fiscal year 2017, and indirect costs were accounted for by our utility estimates.

Results/Complications: Injection therapy offered a minor incremental benefit in quality-adjusted life-years greater than surgical decompression (QALY Δ = 0.6). However, long-term injection therapy was significantly costlier to society than surgical decompression, with treatment estimated at $106,887.96 greater than the cost of surgery. The results of our cost-utility analysis thus conferred a positive ICUR of $178,163.27 in favor of surgical decompression.

Conclusion: Surgery provides a durable intervention and has been shown in this study to be extremely cost-effective despite a very minor QALY deficit in comparison to injection therapy. If patients are identified that require treatment in the form of injections for less than 8.25 years, they may fall into a group that should not be offered surgery.