Updated cost-effectiveness analysis of onabotulinumtoxinA for the prevention of headache in adults with chronic migraine who have previously received three or more preventive treatments in the UK

Figures & data

Table 1. Base case inputs and assumptions.

Criteria	Base case in the revised evaluation	Subgroup analysis from Batty et al.^23
Population	Patients with chronic migraine who have previously received ≥3 oral preventive therapies
Transition probabilities	Calculated using ≥3 prior prophylactics subgroup of PREEMPT
Time horizon	2 years
Negative stopping rule	Patients who do not achieve a reduction in headache days per 28 days of 30% after two 12-week treatment cycles stop treatment
Positive stopping rule	24% of patients whose migraine has changed from chronic to episodic stop treatment
Utility data	EQ-5D from REPOSE	≥3 prior prophylactics subgroup of PREEMPT
Administration and monitoring	One face-to-face follow-up neurology outpatient consultation per 12-week cycle for the onabotulinumtoxinA arm and one consultation every 24 weeks for the placebo arm*	30 min of consultant time per 12-week cycle for both arms with an additional 15 min for administration of onabotulinumtoxinA (using cost per patient-related hour)

* This was the preferred assumption of the Evidence Review Group of the NICE appraisal (TA260)¹⁵.

Figure 1. Markov model diagram of onabotulinumtoxinA for the preventive treatment of chronic migraine. Reproduced from Batty et al.²³.

Figure 2. Transition probabilities with 30% negative stopping rule applied for patients with chronic migraine who have previously received three or more preventive treatments.

Figure 3. Utility values used in the original model (from PREEMPT; number of observations = 359) and the revised model (from REPOSE; number of observations = 3,524) with standard error bars.

Table 2. Cost of care per 12-week cycle by health state.

Health state (headache days per 28 days)	GP visits		ED visits		Hospitalization		Triptan usage		Cost per 12-week cycle
	Number	Subtotal	Number	Subtotal	Number	Subtotal	Number	Subtotal
0–3	0.69	£21.39	0.10	£10.42	0.03	£17.74	1.88	£6.11	£55.67
4–9	0.69	£21.39	0.10	£10.42	0.03	£17.74	5.07	£16.48	£66.03
10–14	0.69	£21.39	0.10	£10.42	0.03	£17.74	5.07	£16.48	£66.03
15–19	2.07	£64.17	0.41	£42.74	0.09	£53.23	7.29	£23.69	£183.83
20–23	2.07	£64.17	0.41	£42.74	0.09	£53.23	7.29	£23.69	£183.83
24+	2.07	£64.17	0.41	£42.74	0.09	£53.23	7.29	£23.69	£183.83

Abbreviations. ED, emergency department; GP, general practitioner.

Table 3. Deterministic base case results with disaggregated costs and QALYs.

	OnabotulinumtoxinA	Placebo	Change
Costs^Λ
Treatment^†	£1,945	£607	£1,337
GP visits	£317	£360	−£43
ED visits	£193	£226	−£32
Hospitalizations	£263	£298	−£36
Triptans	£143	£158	−£16
Total	£2,861	£1,649	£1,211
Total (discounted)	£2,827	£1,623	£1,204
QALYs^Λ
Total	1.23	1.15	0.08
Total (discounted)	1.21	1.13	0.07
ICER			£16,306

^Λ Values presented may not add up precisely to the totals indicated because of rounding.

^† Includes drug costs and administration/monitoring costs.

Abbreviations. ED, emergency department; GP, general practitioner; ICER, incremental cost-effectiveness ratio; QALY, quality-adjusted life year.

Table 4. Deterministic base case results and scenario analyses^Λ.

Scenarios	Totals		Discounted totals		Incremental costs^†	Incremental QALYs^†	ICER
	Costs	QALYs	Costs	QALYs
Deterministic base case results
OnabotulinumtoxinA	£2,861	1.23	£2,827	1.21	£1,204	0.07	£16,306
Placebo	£1,649	1.15	£1,623	1.13
Utilities mapped to EQ-5D from MSQ of PREEMPT
OnabotulinumtoxinA	£2,861	1.11	£2,827	1.09	£1,204	0.06	£19,599
Placebo	£1,649	1.05	£1,623	1.03
Administration by a specialist nurse
OnabotulinumtoxinA	£2,676	1.23	£2,644	1.21	£1,021	0.07	£13,832
Placebo	£1,649	1.15	£1,623	1.13
Time horizon of three years
OnabotulinumtoxinA	£4,032	2.03	£3,920	1.95	£1,399	0.12	£11,629
Placebo	£2,611	1.90	£2,521	1.83
Administration by a specialist nurse and time horizon of three years
OnabotulinumtoxinA	£3,808	2.03	£3,700	1.95	£1,179	0.12	£9,801
Placebo	£2,611	1.90	£2,521	1.83
No positive stopping rule
OnabotulinumtoxinA	£3,183	1.23	£3,138	1.21	£1,515	0.07	£20,768
Placebo	£1,649	1.15	£1,623	1.13
Administration by a specialist nurse and no positive stopping rule
OnabotulinumtoxinA	£2,955	1.23	£2,913	1.21	£1,291	0.07	£17,686
Placebo	£1,649	1.15	£1,623	1.13
Time horizon of three years and no positive stopping rule
OnabotulinumtoxinA	£4,661	2.04	£4,518	1.96	£1,997	0.13	£15,613
Placebo	£2,611	1.90	£2,521	1.83
Administration by a specialist nurse, time horizon of three years, and no positive stopping rule
OnabotulinumtoxinA	£4,349	2.04	£4,215	1.96	£1,694	0.13	£13,245
Placebo	£2,611	1.90	£2,521	1.83

^Λ Calculations based on the values presented may not produce the totals indicated because of rounding.

^† Incremental costs and QALYs based on discounted totals.

Abbreviations. EQ-5D, EuroQol Five-Dimensions; ICER, incremental cost-effectiveness ratio; MSQ, Migraine Specific Quality of Life Questionnaire; QALY, quality-adjusted life year.

Figure 4. Cost effectiveness plane: probabilistic sensitivity analysis results for model base case.

Figure 5. Cost effectiveness acceptability curve: probabilistic sensitivity analysis results for model base case.

Batty AJ, Hansen RN, Bloudek LM, et al. The cost-effectiveness of onabotulinumtoxinA for the prophylaxis of headache in adults with chronic migraine in the UK. J Med Econ. 2013;16(7):877–887.

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NICE [TA260]. Botulinum toxin type A for the prevention of headaches in adults with chronic migraine. London, UK: National Institute for Health and Care Excellence; 2012.

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