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Objective: The objective of this study was to determine the associations among migraine disability assessment scores, healthcare resource utilization (HCRU; medical visits and pharmacy use) and direct medical costs among people with episodic migraine in a real‐world setting. Background: Migraine is a public health concern associated with a substantial economic burden in the United States. However, the association between migraine disability and direct medical costs among people with migraine is unknown. Method: This retrospective, cohort study used claims and electronic health record data from the Decision Resources Group database. Adults with migraine with or without aura, defined by International Classification of Disease Revision 9 (ICD‐9) or ICD Revision 10 (ICD‐10) codes, and a completed Migraine Disability Assessment Scale (MIDAS) questionnaire from January 2016 to December 2018 were included (chronic migraine codes not included). The associations of MIDAS score with the cost of HCRU for the 6 months after MIDAS assessment were explored. Results were stratified by treatment setting. Results: Among 7662 included patients, MIDAS scores were distributed as: 3348 (43.7%; I, little/none), 1107 (14.4%; II, mild), 1225 (16.0%; III, moderate), 893 (11.7%; IVa, severe), and 1089 (14.2%; IVb, very severe). Worsening disability was associated with higher medical costs (adjusted from a multivariable model). In the primary care setting, healthcare visit costs were $206 (95% confidence interval: $144–294) for grade I and $631 ($384–1036) for grade IVb patients; corresponding pharmacy costs were $203 (grade I; $136–301) and $719 (grade IVb; $410–1259). For specialty care (e.g., neurologist), healthcare visits cost $509 ($411–629) for grade I and $885 ($634–1236) for grade IVb patients; corresponding pharmacy costs were $494 (grade I; $378–645) and $1020 (grade IVb; $643–1620). Conclusion: Higher levels of migraine‐related disability (MIDAS assessed) are associated with increased HCRU costs among Americans with episodic migraine. Migraine disability assessment could be useful in the development, testing, and prescription of cost‐effective treatments for people with high migraine‐related disability. [ABSTRACT FROM AUTHOR]