Insights into real-world treatment of cluster headache through a large Italian database: prevalence, prescription patterns, and costs.

Objective: This study aimed at estimating the treated cluster headache (CH) prevalence and describing prescription patterns and direct costs paid by the Italian National-Health-System.Methods: Through the ReS database (healthcare administrative data collection of a large sample of the Italian population), adults in treatment for CH (acute therapy with sumatriptan/subcutaneous or oxygen, associated with preventive therapy with verapamil or lithium) were selected. A cross-sectional analysis described the prevalence of CH-treated subjects repeated annually in 2013-2017. A longitudinal analysis of patients selected in 2013-2015 and followed for 2 years provided the prescription patterns.Results: The annual prevalence of CH-treated patients increased from 6.4×100,000 adults in 2013 to 6.7 in 2017. In 2013-2015, 570 patients (80.7% M; mean age 46) treated for CH were found. In 50.4%, the identifying CH treatment was sumatriptan/subcutaneous+verapamil. During follow-up, >1/3 changed the preventive drug and interruption was the most frequent modification, although acute treatments were still prescribed. The mean annual cost/patient ranged from €2,956 to €2,267; pharmaceuticals expenditure represented the 56.4% and 57.3%, respectively.Conclusions: This study showed an important unmet need among CH patients, carrying a high economic burden that should be considered in the evaluation of the impact of incoming therapies (e.g. Calcitonin-Gene-Related-Peptide antibodies).

Cost-Effectiveness of Reclassifying Triptans in Australia: Application of an Economic Evaluation Approach to Regulatory Decisions.

BACKGROUND: Migraine is a common, chronic, disabling headache disorder. Triptans, used as an acute treatment for migraine, are available via prescription in Australia. An Australian Therapeutic Goods Administration (TGA) committee rejected reclassifying sumatriptan and zolmitriptan from prescription medicine to pharmacist-only between 2005 and 2009, largely on the basis of concerns about patient risk. Nevertheless, pharmacist-only triptans may reduce migraine duration and free up healthcare resources. OBJECTIVES: To estimate the cost-effectiveness of reclassifying triptans from prescription-only to pharmacist-only in Australia. METHODS: The study design included decision-analytic modeling combining data from various sources. Behavior before and after reclassification was estimated using medical practitioner and patient surveys and also administrative data. Health outcomes included migraine frequency and duration as well as adverse events (AEs) discussed by the TGA committee. Efficacy and AEs were estimated using randomized controlled trials and observational studies. RESULTS: Reclassifying triptans will reduce migraine duration but increase AEs. This will result in 337 quality-adjusted life-years gained at an increased cost of A$5.9 million over 10 years for all Australian adults older than 15 years (19.6 million). The incremental cost-effectiveness ratio was estimated to be A$17 412/quality-adjusted life-year gained. CONCLUSIONS: The incremental cost-effectiveness ratio is likely to be considered cost-effective by Australian decision makers. Serotonin syndrome, a key concern of the TGA committee, had little impact on the results. Further research is needed regarding pharmacist-only triptan use by migraineurs currently using over-the-counter medicines and by nonmigraineurs, the efficacy of triptans, and the risk of cardiovascular and cerebrovascular AEs and chronic headaches with triptans.

Prescribing patterns of anti-migraine medicines in South Africa using a claims database.

BACKGROUND: Migraine is an expensive condition impacting on the economically active sector of the population. Given the expense of anti-migraine medicine, it is important to monitor the impact of generic prescribing and therapeutic substitution. OBJECTIVE: The primary aim was to analyse the prescribing patterns and cost of anti-migraine medicines to determine the impact of generic prescribing and prescribing changes over time. METHOD: A retrospective drug utilisation study was conducted on South African private sector medical insurance claims data for 2011. Results A total of 797 patients received 1583 anti-migraine medicines during 2011. The majority of patients (70.14 %) were females. The average age of patients was 41.61 (SD = 14.91) years. Clonidine was the most frequently prescribed (49.21 % of prescribing frequency; 25.70 % of cost), followed by the triptans [selective serotonin (5-HT1B/1D)-receptor agonists] (27.98 % of prescribing frequency; 45.92 % of cost). Five triptans were prescribed. The average cost per sumatriptan prescription was the lowest (the only triptan with generic equivalents). Rizatriptan was the most frequently prescribed triptan (18.51 % of prescribing frequency; 29.15 % of cost). CONCLUSION: The results were generally in agreement with previous South African studies. The impact of the introduction of newer triptans and of generic equivalents on prescribing patterns was clear.

Migraine-related healthcare resource use and costs for subjects prescribed fixed-dose combination sumatriptan/naproxen sodium vs. single-entity oral triptans in a managed care population in the USA.

BACKGROUND: Randomized clinical trials have demonstrated that the efficacy of a fixed-dose single-tablet combination containing sumatriptan and naproxen sodium (S/NS) was greater than either of its individual components. Simplifying drug regimens (e.g., via a fixed-dose combination) has been shown to improve "real-world" outcomes by reducing pill burden and treatment regimen complexity, improving adherence, and reducing healthcare resource use and associated costs; however, no studies assessing such outcomes have been conducted to date for the acute treatment of migraine. OBJECTIVE: To assess migraine-related healthcare resource use and associated costs for subjects prescribed S/NS vs. subjects prescribed single-entity oral triptans (SOTs) within a managed care population in the USA. METHODS: In this retrospective analysis of administrative claims data from July 1, 2008 to December 31, 2009 (IMS LifeLink), subjects meeting the following criteria were selected: one or more pharmacy claim(s) for either S/NS or SOT (index date), aged 18-64 years; at least one migraine diagnosis, and continuous enrollment in the 6 months prior to and post the index date. The study population was subsequently stratified for two analyses: triptan-naïve (triptan naïve in the 6-month period prior to the index date) and triptan-switch (triptan user in the 6-month period prior to the index date and switching to another triptan). Subjects prescribed S/NS were propensity-score matched with subjects prescribed SOT (triptan-naïve analysis: 1:3; triptan-switch analysis: 1:1) to assess differences in healthcare resource use and associated costs (2009 US$) between the S/NS and SOT groups. RESULTS: Results from the triptan-naïve and triptan-switch analyses suggest that subjects prescribed S/NS are likely to have similar healthcare resource use patterns as those either newly initiated on an SOT or switching SOTs, as measured by migraine medication use, migraine-related healthcare resource use, and all-cause healthcare resource use. One exception was the observed increased use of opioids in the SOT group compared with the S/NS group (change in mean number of tablets pre-index vs. post-index, S/NS vs. SOT; triptan-naïve analysis: 8.6 vs.18.3, p = 0.045; triptan-switch analysis: -8.2 vs. 17.7; p = 0.120). Total costs from the triptan-naïve analysis indicated that the S/NS group had lower migraine-related (US$744 vs. US$820; p = 0.067) and all-cause healthcare costs (US$4,391 vs. US$4,870; p = 0.040) when compared with the SOT group, driven by savings in medical costs (migraine-related: US$252 vs. US$380; p = 0.001; all-cause: US$3,023 vs. US$3,599; p = 0.014). However, no significant differences were observed for total costs from the triptan-switch analysis (migraine-related healthcare costs, S/NS vs. SOT: US$1,159 vs. US$1,117; p = 0.929; all-cause healthcare costs: US$5,128 vs. US$4,788; p = 0.381). CONCLUSION: Study results suggest similar healthcare resource use patterns and associated costs when comparing S/NS and SOT across a triptan-naïve and triptan-experienced population. While the current study focuses on direct medical costs, future studies should extend beyond such a perspective to explore functional status, productivity, and health-related quality of life and satisfaction, attributes not captured in administrative claims data, but nonetheless important treatment goals.

Costs of hypothalamic stimulation in chronic drug-resistant cluster headache: preliminary data.

In about 20% of chronic cluster headache (CH) cases, drugs may become ineffective. Under these circumstances, steroids and triptans are frequently employed leading to fearful side effects in one and high costs in the other. The direct costs of drug-resistant chronic CH are mainly due to frequent medical consultations and frequent use of expensive drugs. In recent years, hypothalamic stimulation has been employed to treat drug-resistant chronic CH patients suffering multiple daily attacks and long-term results from different centres show a 60% overall benefit. Nine years since the introduction of this technique, we attempt a preliminary analysis of the direct costs of hypothalamic stimulation based on patients treated at our centre. We estimated the following direct costs as follows: cost of neurosurgery plus cost of equipment (electrode, connection and impulse generator = 25,000 euro), cost of hospital admissions in long-term follow-up (2,000 euro per admission), cost of single sumatriptan injection (25 euro). Number of daily sumatriptan injections in the year before and for each year after hypothalamic implantation was obtained from headache diaries. To estimate the saving due to the reduction in sumatriptan consumption following hypothalamic stimulation, we calculated the following for each year of follow-up after surgery: number of sumatriptan injections in the year before surgery minus number of sumatriptan injections in each year, updated to December 2008. In our 19 implanted patients, the costs of neurosurgery plus cost of equipment were 475,000 euro; the costs of hospital admissions during follow up were 250,000 euro. Reduction in sumatriptan consumption resulted in a total saving of 3,573,125 euro. Hence, in our 19 patients, the sumatriptan saving (3,573,125 euro) minus the direct costs due to operation and follow up hospitalisations (475,000 + 250,000) euro is equal to 2,848,125 euro. These preliminary results indicate that hypothalamic stimulation is associated with marked reduction of direct costs in the management of complete drug-resistant chronic CH.

Assessment of clinical, service, and cost outcomes of a conversion program of sumatriptan to rizatriptan ODT in primary care patients with migraine headaches.

OBJECTIVE: Managed care organizations can increase the value of drug therapy by negotiating discounts on drug acquisition costs with pharmaceutical manufacturers and promoting use of preferred drugs, including the conversion of patients to preferred medications. This investigation was designed to assess conversion success, migraine drug utilizations, and patient satisfaction with a clinical pharmacist-managed conversion program from sumatriptan to rizatriptan ODT, both formulary drugs. METHODS: This was a retrospective cohort study conducted in a managed care organization for patients aged 18 years or older who had picked up at least one outpatient prescription for any sumatriptan dosage form at the pharmacy between January 2002 and June 2002. Patients. pharmacy and medical data were reviewed to assess eligibility (e.g., no history of rizatriptan failure) for conversion from sumatriptan to rizatriptan orally disintegrating tablet (ODT). There was no copayment difference for members for rizatriptan ODT versus sumatriptan. A questionnaire was developed to assess 2 domains: (1) patient satisfaction with the medication conversion process and (2) preference for rizatriptan ODT or sumatriptan. A random sample of 315 patients who initiated conversion to rizatriptan ODT was surveyed. Electronic pharmacy claims were reviewed to determine the number of patients who were successfully converted from sumatriptan to rizatriptan ODT. Pharmacy expenditures and total health care utilization and expenditures in the 180 days prior to (baseline) and after the conversion (followup) to rizatriptan ODT were compared for the cohorts of subjects who were successfully converted and those patients who were not successfully converted. RESULTS: Therapeutic conversion from sumatriptan to rizatriptan ODT was attempted in 457 patients; 214 (47%) were successfully converted. The only difference between the 2 cohorts at baseline for the 6 months prior to attempted conversion was a higher mean number of sumatriptan doses per patient per month (PPPM) in the 243 failed conversions (mean 3.5, SD 2.9) compared with the 214 successful conversions (mean 2.8, SD 2.8, P =0.003). The median triptan doses increased by 1.0 PPPM in both cohorts (P =0.882), from 2.0 to 3.0 doses PPPM in the group of successful conversions and from 2.7 to 4.0 in the group of unsuccessful conversions. The survey response rate was 55% for both successful and for unsuccessful conversions. More than 90% of the patients in both cohorts were satisfied with the level of care provided by the clinical pharmacy staff during medication conversion, and there was no difference between the 2 cohorts in patient satisfaction (P=0.761). Rizatriptan ODT was preferred by 68.0% and 8.5% of successful and failed conversion subjects, respectively (P <0.001). Using representative group purchase prices, triptan expenditures for successful conversion subjects were reduced by a median of -2 dollars (6 %) PPPM while triptan expenditures for unsuccessful conversions increased by a median of 8 dollars (P <0.001). There were no differences for either cohort in median PPPM changes in migraine-related office visits (0.0 median change in office visits, P =0.748) or office-visit costs (0 dollars median change, P =0.861) for preconversion versus postconversion attempts Regression modeling identified that lower total counts of sumatriptan doses filled during baseline period was an independent predictor of successful conversion to rizatriptan ODT (P <0.001). There was an average of 3.5 triptan medication fills per patient for successful conversion during the 6-month follow-up period, with 78% of these subjects filling at least 2 prescriptions for rizatriptan ODT during this period. CONCLUSIONS: This conversion program for sumatriptan to rizatriptan ODT was successful in converting almost half of primary care patients to the preferred product despite the absence of a copayment incentive for members to agree to the conversion. There were no measurable medical or economic consequences of the conversion, and patient satisfaction with the quality of care was maintained. Future efforts are likely to have a higher success rate if focused on converting patients with less-severe migraine headaches, as measured by the need for baseline rescue medication, since lower acuity was the only independent predictor of successful conversion in this conversion program for 2 triptan drugs.

Cost-effectiveness analysis of rizatriptan and sumatriptan versus Cafergot in the acute treatment of migraine.

BACKGROUND: Both ergotamine and selective serotonin 5-HT(1B/1D) receptor agonists ('triptans') are currently used in the treatment of moderate to severe migraine. Ergotamine is a traditional therapy with a lower drug acquisition cost compared with triptans. It has been shown that triptans are more efficacious than ergotamine, but the higher acquisition costs and shorter duration of action are disadvantages of triptans compared with ergotamine. OBJECTIVE: The purpose of this study was to provide a comparison of the cost-effectiveness of rizatriptan 10 mg and sumatriptan 50 mg tablets with that of a fixed-dose combination of ergotamine tartrate plus caffeine (Cafergot) in the treatment of an acute migraine attack. The cost-effectiveness of rizatriptan in comparison with sumatriptan was also assessed. METHODS: Three separate decision tree models were developed (model 1: rizatriptan vs Cafergot; model 2: sumatriptan vs Cafergot; model 3: rizatriptan vs sumatriptan). The time horizon was 1 year. Cost-effectiveness analysis was conducted from the societal perspective using cost and effectiveness estimates from the literature. All costs were converted to US dollars (2003). The cost-effectiveness ratio was expressed as incremental cost per quality-adjusted life-year (QALY) gained. RESULTS: Base case evaluation showed that both rizatriptan and sumatriptan dominated Cafergot. The net annual saving associated with use of rizatriptan was US dollars 622.98 per patient, with an incremental QALY of 0.001. Use of sumatriptan resulted in a saving of US dollars 620.90 and an increase in QALY. The cost-effective ratios were not sensitive to changes in key variables such as efficacy, utility, drug costs, hospitalisation cost and patient preference over alternative therapies. The study further showed that rizatriptan is more cost effective than sumatriptan, as evidenced by its lower cost and greater effectiveness. Sensitivity analysis showed that the cost-effectiveness ratios were sensitive to moderate changes in drug efficacy. CONCLUSION: Rizatriptan and sumatriptan were less costly and more effective than Cafergot in the treatment of an acute migraine attack. Rizatriptan was somewhat less costly and more effective than sumatriptan. Additional quality-of-life studies are needed to confirm the benefits of using triptans in the management of migraine.

Oral serotonin receptor agonists: a review of their cost effectiveness in migraine.

Migraine headache is a highly prevalent chronic, episodic condition. The direct and indirect costs of migraine headache have a tremendous economic impact in the US. Research has shown that serotonin (5HT(1B/D)) receptor agonists reduce healthcare costs, improve health-related QOL (HR-QOL), decrease migraine disability and keep patients effective in the workplace. The purpose of this manuscript is to examine the cost effectiveness of oral 5HT(1B/D) receptor agonists for the treatment of migraine headache. In general, 5HT(1B/D) receptor agonists are associated with increases in direct healthcare costs; however, they are also associated with reductions in the indirect costs associated with migraine headache. Therefore, it appears that the relatively high acquisition cost of these medications is offset and, as a class, these medications appear to be cost effective and demonstrate net benefits from the societal perspective. Based on meta-analyses in which data on eletriptan were not available, it appears that within the class, almotriptan and rizatriptan are the most cost effective. In a prospective study comparing eletriptan with sumatriptan, it appears that the former may be more cost effective than the latter. Additional investigations are needed to further explore the application of the friction-cost approach and QALYs to cost-effectiveness analyses of this class of medication.

A comparison of the cost-effectiveness of almotriptan and sumatriptan in the treatment of acute migraine using a composite efficacy/tolerability end point.

OBJECTIVE: To use a composite efficacy/tolerability end point to compare the cost-effectiveness, from the perspective of a U.S. health care payer, of almotriptan and sumatriptan in the treatment of an acute migraine attack. METHODS: The composite end point. Sustained pain free and No Adverse Events. (SNAE) was created from the sustained pain free and adverse event rates obtained in a meta-analysis of 53 placebo-controlled trials of oral triptans. The total direct cost of treating a single migraine attack was calculated from published sources. RESULTS: In the base-case analysis, the average cost-effectiveness ratios (CERs) were 82 US dollars , 133 US dollars , and 138 US dollars (per attack at which SNAE is achieved, 2004 prices) for almotriptan 12.5 mg, sumatriptan 50 mg, and sumatriptan 100 mg, respectively; the incremental CERs for almotriptan 12.5 mg were 12 US dollars and 16 US dollars (compared with sumatriptan 50 mg and sumatriptan 100 mg, respectively) per incremental attack at which SNAE is achieved. Sensitivity analyses were conducted to explore the impact of (1) relaxing the base-case assumptions (independence of efficacy and tolerability, uniform apportionment of health service use costs across attacks, number of tablets used to treat 1 attack); (2) varying input costs; and (3) uncertainty in the efficacy and tolerability estimates from the meta-analysis. In all of these sensitivity analyses, almotriptan 12.5 mg remained cost effective compared with sumatriptan 50 mg and 100 mg. CONCLUSION: Almotriptan was economically superior to sumatriptan in the treatment of a migraine attack.

The disparity in access to new medication by type of health insurance: lessons from Germany.

BACKGROUND: Drug provision within the German statutory health insurance system has undergone several reforms, including the introduction of drug macrobudgets in 1993. OBJECTIVE: The objective of this study was to investigate the extent to which statutorily (SHI) and fully privately (PHI) health-insured patients were provided with new medication recommended by professional bodies in an equitable fashion using the example of migraine patients. RESEARCH DESIGN: We conducted a retrospective cohort study. SETTING: A total of 367 primary-care practices (MediPlus, IMS Health) in Germany in the second year of the HealthCare Structural Reform Act were studied. SUBJECTS: Subjected consisted of 7703 SHI and 470 PHI migraineurs (International Classification of Diseases, 10th edition G43) aged 18 to 65 years at their first migraine prescription visit in 1994. OUTCOME MEASURE: We compared prescription of oral or subcutaneous serotonin 5HT1B/1D receptor agonist sumatriptan with nonserotoninergic migraine therapy. RESULTS: In multiplicative risk regression with variance estimation accounting for clustering of patients within practices, PHI patients were 2.3 times (95% confidence interval [CI], 1.6-3.3) more likely to receive sumatriptan than their SHI counterparts at the mean age of the cohorts (43 years) adjusted for incident versus prevalent migraine treatment, the gender of the patient, the age, gender, and primary care specialist group of the physician, and the type and the community size class of the practice. This disparity widened by 38% (95% CI, 1-88%) every 10 years of patient age. CONCLUSION: Even though virtually everyone in Germany has health insurance and drug coverage, use of new and recommended migraine medicines was less common among those with SHI compared with their privately insured counterparts. Systematic studies of access to health care recommended by professional bodies will be critically important to ensure delivery of high-quality health care for all patients.

Meta-analysis of oral triptan therapy for migraine: number needed to treat and relative cost to achieve relief within 2 hours.

OBJECTIVE: To determine the cost-effectiveness of the 5-HT1B/1D agonists, or triptans, in the acute treatment of migraine. METHODS: To determine the cost-effectiveness of the triptans, a meta-analysis was conducted of the efficacy data from 27 oral triptan trials, using the endpoint of "pain-free" status within 2 hours after initial dosing as the indicator of efficacy. Efficacy data were used to determine the number needed to treat (NNT) to achieve pain-free status in 1 patient within 2 hours postdose and then applied the per-dose costs for each triptan to the NNT values. RESULTS: Rizatriptan 10 mg and almotriptan 12.5 mg were the most cost-effective of the triptans, costing $48.34 and $48.57 US dollars, respectively, to achieve pain-free status in 1 patient within 2 hours postdose. Frovatriptan 2.5 mg was the most costly, with a cost-effective ratio of $162.49 US dollars. All other triptans fell between these extremes: zolmitriptan 5 mg ($65.18 US dollars), sumatriptan 100 mg ($70.83 US dollars), sumatriptan 50 mg ($75.67 US dollars), zolmitriptan 2.5 mg ($78.74 US dollars), and naratriptan 2.5 mg ($141.43 US dollars), in decreasing order of cost-effectiveness. CONCLUSION: Using an NNT analysis, the least-costly drugs to achieve migraine cure within 2 hours are rizatriptan 10 mg and almotriptan 12.5 mg. From a population health perspective, the lower acquisition cost of almotriptan 12.5 mg allows for effective treatment of more patients than rizatriptan 10 mg for no additional medication cost.

A cost-effectiveness analysis of eletriptan 40 and 80 mg versus sumatriptan 50 and 100 mg in the acute treatment of migraine.

OBJECTIVES: This article explores the application of cost-effectiveness analysis in a comparison of eletriptan and sumatriptan in the acute treatment of migraine. METHODS: The study employs data from a randomized, double-blind, placebo-controlled clinical trial comparison of oral eletriptan (40 and 80 mg) and oral sumatriptan (50 and 100 mg). Analyses were undertaken using two composite measures of treatment outcome constructed to reflect the requirements of patients more comprehensively than the conventional efficacy indicator of headache response at 2 hours. On the cost side of the equation, reflecting the health-care system perspective of the analysis, drug costs for initial dosing, second dosing for nonresponse, and recurrence and rescue medication were taken into account. RESULTS: The analysis found that eletriptan treatment resulted in lower costs per successfully treated attack than those of sumatriptan under both outcome criteria. CONCLUSION: Further refinement of outcomes measurement in migraine would be valuable and eletriptan has a potentially important role to play in the cost-effective management of the disorder.

Migraine preventive medication reduces resource utilization.

OBJECTIVE: To determine if long-term resource utilization is reduced by adding a preventive medication to a migraine management regimen that already includes acute medication. BACKGROUND: In 2000, new evidence-based guidelines for the treatment of migraine were released by the US Headache Consortium and the American Academy of Neurology. Although these guidelines emphasize the role of preventive medication in achieving significant clinical improvement, little yet is known concerning the impact of such management on medical and pharmaceutical resources. Methods.-Resource utilization information in a large claims database was analyzed retrospectively. RESULTS: Adding a preventive medication to migraine management reduced the use of other migraine medications, as well as visits to physician offices and emergency departments. In addition, both acute and preventive medications were associated with lower utilization of computed tomography and magnetic resonance imaging scans. CONCLUSION: Migraine preventive drug therapy is effective in reducing resource consumption when added to therapy consisting only of an acute medication.

Ergot and triptan overuse in Austria--an evaluation of clinical data and cost.

Austria is one of the countries, in which ergots are still the most commonly used acute anti-migraine drugs. Overuse and chronification is a clinical problem for ergots, but also for the recently developed triptans. In a retrospective study for the year 1999 we evaluated clinical data from all Austrian neurological hospitals including cost of withdrawal as well as the estimated cost for ergots and triptans on the pharmaceutical retail market. We identified a total of 96 patients that underwent withdrawal, all of whom because of ergot overuse, and some with considerable long-term side-effects. The cost of withdrawal (more than 1300 000) together with direct cost of medication amounted to more than 11 million. In contrast, cost of medication for triptans was 12.8 million for the same year, without any cost for withdrawal. If only cost aspects were to be considered in the prescription of acute anti-migraine drugs, our data would suggest to choose ergots rather than triptans. However, as scientific evidence is clearly in favour of triptans, decision making for the prescribing clinicians is more complex and will primarily focus on optimizing patient care, but also depend on the respective socio-economic situation.

Cost-effectiveness of antiepileptic drugs in migraine prophylaxis.

OBJECTIVE: To analyze the cost-effectiveness of antiepileptics in migraine prophylaxis. METHODS: A cost-effectiveness analysis was performed using efficacy data from three recent, double-blind, placebo-controlled, clinical trials of antiepileptic drugs studied for migraine prevention and cost data. Two measures of cost-effectiveness were used: cost per headache prevented and the cost-equivalent number. RESULTS: In the double-blind, placebo-controlled, clinical trials evaluated, three antiepileptic drugs were shown to be effective in migraine prevention. All three antiepileptic drugs had high costs per migraine reduced. Gabapentin was the most costly at dollars 138.00 per migraine prevented, whereas the cost per migraine prevented with topiramate was US dollars 114.80 and with divalproex sodium was US dollars 48.00. For migraine prevention divalproex sodium became cost-effective with 10 migraines per month, whereas gabapentin and topiramate required considerably more migraines per month to be cost-effective. CONCLUSIONS: Antiepileptic drugs have proven effectiveness in migraine prophylaxis. However, in patients responsive to their acute care medications, the antiepileptic drugs are only cost-effective for those patients with a high frequency of migraines and those with comorbid diseases. Future studies should be done with antiepileptic drugs in patients exhibiting a migraine frequency of 10 or more headaches per month.