OBJECTIVES: Determine the cost-effectiveness of facial plastic surgery vs. OnabotulinumtoxinA for chronic migraine prophylaxis . METHODS: A Markov model comparing Onabotulinumtoxin A to a relatively new surgical treatment for chronic migraine headache was constructed from the payer perspective with a lifetime time horizon and one month cycle length. Efficacy and adverse event data were sourced from randomized, controlled trials of the two interventions relative to placebo or standard care, while costs came from mean wholesale pricing of OnabotulinumtoxinA and proxy surgery costs. Utility scores were obtained for four Markov health states based on monthly headache frequency <2, >15; and death. Subjects were assumed to start in a chronic migraine state. Costs and utility were discounted at 2%. Uncertainty was evaluated through one-way and probabilistic sensitivity analyses. All analysis was completed in Microsoft Excel 2013 (Redmond, WA). One-way sensitivity analysis was conducted using TreePlan, SensIt 1.46 (San Francisco, CA). RESULTS: Onabotulinum toxin A was significantly more expensive than surgery, while the two treatments had similar efficacy and surgery had fewer adverse effects. Surgical and post-surgical care costs were $7,850 (95% CI $3,500; $20,000) compared to $25,000 (95% CI $15,000; 37,000); p<0.001. Reduction in headache days was not significantly different between the interventions. A single surgical intervention for migraine has fewer side effects than quarterly OnabotulinumtoxinA treatments. Surgery dominates OnabotulinumtoxinA. CONCLUSIONS: Surgery should be considered for chronic migraine. Third-party payers may be hesitant to pay for surgery given the larger upfront costs, while the benefits accrue over time – when the patient may be with a different payer.