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

Surgical Management of Headache Disorders - A Systematic Review of the Literature

PURPOSE OF REVIEW

This review article critically evaluates the latest advances in the surgical treatment of headache disorders.

RECENT FINDINGS

Studies have demonstrated the effectiveness of innovative screening tools, such as doppler ultrasound, pain drawings, magnetic resonance neurography, and nerve blocks to help identify candidates for surgery. Machine learning has emerged as a powerful tool to predict surgical outcomes. In addition, advances in surgical techniques, including minimally invasive incisions, fat injections, and novel strategies to treat injured nerves (neuromas) have demonstrated promising results. Lastly, improved patient-reported outcome measures are evolving to provide a framework for comparison of conservative and invasive treatment outcomes. Despite these developments, challenges persist, particularly related to appropriate patient selection, insurance coverage, delays in diagnosis and surgical treatment, and the absence of standardized measures to assess and compare treatment impact. Collaboration between medical/procedural and surgical specialties is required to overcome these obstacles.

Nonpharmacologic Treatments for Chronic and Episodic Migraine: A Systematic Review and Meta-Analysis

BACKGROUND

Minimally invasive techniques for treatment-resistant migraine have been developed on recent insights into the peripheral pathogenesis of migraines. Although there is a growing body of evidence supporting these techniques, no study has yet compared the effects of these treatments on headache frequency, severity, duration, and cost.

METHODS

PubMed, Embase, and Cochrane Library databases were searched to identify randomized placebo-controlled trials that compared radiofrequency ablation, botulinum toxin type A (BT-A), nerve block, neurostimulation, or migraine surgery to placebo for preventive treatment. Data on changes from baseline to follow-up in headache frequency, severity, duration, and quality of life were analyzed.

RESULTS

A total of 30 randomized controlled trials and 2680 patients were included. Compared with placebo, there was a significant decrease in headache frequency in patients with nerve block ( P = 0.04) and surgery ( P < 0.001). Headache severity decreased in all treatments. Duration of headaches was significantly reduced in the BT-A ( P < 0.001) and surgery cohorts ( P = 0.01). Quality of life improved significantly in patients with BT-A, nerve stimulator, and migraine surgery. Migraine surgery had the longest lasting effects (11.5 months) compared with nerve ablation (6 months), BT-A (3.2 months), and nerve block (11.9 days).

CONCLUSIONS

Migraine surgery is a cost-effective, long-term treatment to reduce headache frequency, severity, and duration without significant risk of complication. BT-A reduces headache severity and duration, but it is short-lasting and associated with greater adverse events and lifetime cost. Although efficacious, radiofrequency ablation and implanted nerve stimulators have high risks of adverse events and explantation, whereas benefits of nerve blocks are short in duration.

Migraine Surgery and Determination of Success over Time by Trigger Site: A Systematic Review of the Literature

BACKGROUND

Migraine headache is a debilitating disorder that produces high costs and compromises patient quality of life. This study aimed to evaluate surgery success and the longevity of the surgical benefit by trigger site.

METHODS

A systematic literature review was performed by querying the PubMed, Embase, Scopus, and Web of Science databases. The keywords "surgery," "migraine," "outcomes," "headache index," and synonyms in titles and abstracts were used to perform the search.

RESULTS

A total of 17 articles published between 2009 and 2019 met the inclusion criteria. Six studies were prospective and 11 were retrospective. Most of the studies (77.8%, 77.8%, and 80%, respectively) reported success of migraine surgery at 12-month follow-up for trigger sites I, II, and III, respectively. For trigger site IV, the greatest Migraine Headache Index reduction (93.4%) was observed at 12-month follow-up, and the earliest Migraine Headache Index reductions (80.3% and 74.6%) were observed at 6-month follow-up. All studies that evaluated trigger sites V and VI identified surgery success at 12-month follow-up. Migraine surgery was found to remain beneficial at 22 months for trigger sites I, II, III, and IV.

CONCLUSIONS

The symptomatic improvement may initially be evident at 6 months for trigger site IV and at 12 months for trigger sites I, II, III, V, and VI. Surgical benefit in trigger sites I, II, III, and IV can persist after 22 months. Further studies are required to evaluate results at longer follow-up.

Current Evidence in Migraine Surgery: A Systematic Review

INTRODUCTION

Migraine headache is a widespread neurovascular disorder with an enormous social and economic impact. A subgroup of patients cannot be managed with pharmacological therapy. Although surgical decompression of extracranial sensory nerves has been proposed as a valid alternative treatment option, the medical community remains reluctant to accept it.

MATERIALS AND METHODS

This systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. An electronic search was performed in September 2020 on PubMed, ScienceDirect, CENTRAL, and Google Scholar databases for original articles reporting outcomes on migraine surgery.

RESULTS

The search strategy revealed a total of 922 studies, of which 52 were included in the review. Significant improvement was reported in 58.3% to 100% and complete elimination in 8.3% to 86.8% of patients across studies. No major complications were reported.

DISCUSSION

This systematic review demonstrates that migraine surgery is an effective and safe procedure, with a positive impact in patients' quality of life and a reduction in long-term costs.

CONCLUSION

There is considerable scientific evidence suggesting extracranial migraine surgery is an effective and safe procedure. This surgery should be considered in properly selected migraineurs refractory to medical treatment.

A Markov Analysis of Surgical versus Medical Management of Chronic Migraines

BACKGROUND

Refractory chronic migraine is a common and debilitating neurologic condition, affecting over 8 million people in the United States. It is associated with billions of dollars in lost productivity annually. Novel medical (anti-calcitonin gene-related peptide antibodies) and surgical treatment modalities have emerged for chronic migraine in recent years. The current study investigated the cost-utility of surgical versus medical management of refractory chronic migraine.

METHODS

A Markov cohort analysis using hybrid Monte Carlo patient simulation was performed to compare surgical decompression versus erenumab for the treatment of refractory chronic migraine in adults. Both societal and payer perspectives were considered. Primary model outcomes included incremental cost-effectiveness ratio, or cost per quality-adjusted life-year gained.

RESULTS

Over a 5-year period, migraine surgery was associated with an increase of 0.2 quality-adjusted life-year per patient when compared to erenumab. In terms of costs, the results demonstrated a $19,337 decrease in direct medical costs and a $491 decrease in indirect costs (productivity lost) for the surgery cohort compared to erenumab. Because surgery improved quality of life and decreased costs compared to erenumab, even when considering revision surgery needs, surgery was the overall dominant treatment in terms of cost-effectiveness. Sensitivity analyses demonstrated that surgery was cost-effective compared to erenumab when patients required therapy for at least 1 year.

CONCLUSIONS

Surgical deactivation of migraine trigger sites may pose a cost-effective approach to treating refractory chronic migraine in adults. This is especially the case when patients are anticipated to require therapy for more than 1 year.

Health economic evaluation of different treatment strategies for peripheral entrapment mononeuropathies: a systematic review

Introduction: In this era of cost-conscious health systems, it is of utmost importance to identify and establish the most cost-effective treatment option. However, in the case of peripheral entrapment mononeuropathies there is alack of data regarding economically effective treatment strategies. Therefore, the objective was to conduct an economic evaluation including both costs and benefits of various treatment strategies applied to peripheral entrapment mononeuropathies to estimate the relative cost-effective treatment regimens.Areas covered: Over the 19 years, seven excellent-high quality economic evaluations of three types of peripheral entrapment mononeuropathies were identified in four countries. Our findings showed that surgery was the most cost-effective therapy followed by same cost efficacy of infiltrative therapy and conservative therapy for peripheral entrapment mononeuropathies. However, the fact that surgery was the most common comparator (n = 6) in our selected studies cannot be neglected.Expert opinion: Due to huge methodological variability, the finding of surgery as the cost-effective treatment strategy remains tentative and the decision about the most suitable clinical and cost-effective therapy should be individualized from case to case. Moreover, the economic evaluation of all possible treatment strategies for peripheral entrapment mononeuropathies over alonger period of analysis is required in future studies.

Economic Evaluation of Treatments for Migraine: An Assessment of the Generalizability Following a Systematic Review

BACKGROUND

All health economics reviews on chronic and episodic migraine published to date underline the heterogeneity of results. Currently, the need for the generalizability of economic evaluations across different jurisdictions is considered a key issue to avoid unnecessary overlaps and to minimize the time to reimbursement decisions.

OBJECTIVE

The aim of this study was to review the economic evaluations on the prophylaxis and treatments for migraine published in the previous 10 years (since 2009) and to perform a critical assessment of their generalizability.

METHODS

We searched PubMed, EMBASE, and EconLit databases. Articles underwent a three-stage selection process. To assess the level of generalizability, we used the checklist implemented by Augustovski et al. Studies were classified as: (1) generalizable; (2) transferable; and (3) context specific.

RESULTS

In total, 227 articles were identified after running the search string and 11 studies were included in our review. Overall, none of the studies was judged as generalizable and three were judged transferable according to the established criteria.

CONCLUSIONS

Our review suggests that no evidence on the economic value of either acute or prophylactic treatments against migraine is generalizable to different jurisdictions. However, the majority of studies reporting results about prophylactic treatments were found to be transferable.

Assessment of Wellbeing and Anxiety-related Disorders in Those Seeking Rhinoplasty: A Crowdsourcing-based Study

BACKGROUND

Recently, it has been proposed that psychosocial concerns may motivate the demand for aesthetic rhinoplasty. Although successful operations often improve the quality of life and self-esteem symptoms in patients with sound mental health, they may actually result in unsatisfactory outcomes in those patients with significant depression, anxiety, or other severe psychological disorders. The purpose of this study was to assess the incidence of psychological disorders in patients seeking rhinoplasty.

METHODS

A prospective cross-sectional study of 298 random volunteers was conducted, with each participant completing a survey instrument that was administered through an internet crowd-sourcing service (Amazon Mechanical Turk). Participants were asked to complete a 10-item standardized SHNOS scale, and a 26-question PRIME-MD questionnaire in order to assess functional and aesthetic need for rhinoplasty, and the incidence of psychological disorders respectively.

RESULTS

38.95% of female participants reported a willingness to undergo aesthetic rhinoplasty, with a significantly lower number of men reporting the same (27.78%, P = 0.042). Adults between the ages of 18-24 (52.92%) were more willing to undergo aesthetic rhinoplasty, as compared to any other age group (P < 0.01). It was found that 57.84% of patients interested in surgery reported a psychological disorder as determined by the PRIME-MD questionnaire.

CONCLUSIONS

Those suffering from major depressive disorder, generalized anxiety disorder, or body dysmorphic disorder may seek aesthetic rhinoplasty as a solution. It is important that surgeons assess patient mental health prior to treatment in order to avoid unsuccessful outcomes secondary to psychosocial illness.

Defining "Ideal Abs" Through a Crowdsourcing-Based Assessment

BACKGROUND

There were almost 12 million nonsurgical cosmetic procedures performed in the United States in 2016, which represented a 12% increase from the previous year, and popularity is expected to continue rising. Furthermore, nonsurgical fat reduction and body contouring have experienced a dramatic increase in popularity among both men and women. However, there has been very little work focused on the public's perception of the ideal abdominal muscles.

OBJECTIVES

The authors sought to analyze patient perspectives on ideal abdominal contours and attitudes towards methods of improving the appearance of the abdomen.

METHODS

A prospective cross-sectional study of 718 random volunteers recruited through Amazon Mechanical Turk was conducted. A survey instrument was administered to all study participants to assess the importance of ab symmetry, pec muscle definition, serratus muscle definition, and natural feel.

RESULTS

Study participants across all ages, gender, ethnicity, and marital status indicated that a 6-pack was the ideal abdominal muscle count. They also rated the symmetry (61.06 ± 1.87) and natural feel of abs (60.72 ± 1.75) as the 2 most important aesthetic features in consideration of ideal abs. Study participants who reported exercising more than twice a week expressed a greater interest in nonsurgical procedures to achieve ideal abs (P = 0.007).

CONCLUSIONS

"Ideal abs" are 6 in number, symmetric, and feel natural. Millennials are much more willing to consider nonsurgical options to achieve ideal abs instead of surgery. Individuals who maintain a high level of fitness are, interestingly, more likely to want ideal abs and nonsurgical methods to achieve them.