BACKGROUND: Migraine affects approximately 40 million adults in the US and is a significant source of morbidity and lost productivity. In some patients, commonly used migraine treatments are ineffective, not tolerated or have contraindications. New treatments are needed, but anticipated higher costs may limit patient access.

OBJECTIVES: To evaluate the long-term cost-effectiveness of lasmiditan, rimegepant, and ubrogepant for acute migraine in two distinct patient populations, compared with 1) “usual care” in patients who cannot take triptans (i.e. a prevalent mix of treatments excluding triptans); and 2) triptans in triptan-naïve patients.

METHODS: A semi-Markov model was developed, employing 48-hour cycles over 2 years, from a health care sector perspective. Outcomes, utility, and most cost inputs were obtained through manufacturer-submitted evidence, systematic literature reviews, and clinical expert opinion. Drug prices are not publicly available and were assumed to be 20% greater than branded sumatriptan (Imitrex^®). Primary outcomes, discounted at 3% annually, were incremental cost per QALY and cost per pain-free hour. One-way and probabilistic sensitivity analyses were conducted to evaluate uncertainty.

RESULTS: At the assumed prices, incremental cost-effectiveness ratios (ICERs) for lasmiditan, rimegepant, and ubrogepant, compared with usual care, were $327,700, $559,500 and $569,600, respectively. When compared with triptans, sumatriptan and eletriptan dominated. In sensitivity analyses, ICERs were affected considerably by many inputs, although none resulted in an ICER under $150,000 per QALY gained compared with usual care. In probabilistic sensitivity analyses, and at a threshold of $250,000 per QALY gained, lasmitidan, ubrogepant, and rimegepant achieved cost-effectiveness in 9.4%, 0.2%, and 0.0% of trials, respectively.

CONCLUSIONS: Lasmiditan, rimegepant, and ubrogepant may provide an important therapeutic alternative to current treatments for acute migraine in patients who cannot tolerate or have contraindications to triptans. Pricing of these drugs will determine whether they are cost effective at commonly accepted thresholds.