The 2023 VA/DoD clinical practice guideline was revised early to include CGRP inhibitors (gepants and monoclonal antibodies) as recommended options for both acute migraine treatment and episodic migraine prevention.
52 recommendationsIncluding CGRP gepants for acute treatment and CGRP antibodies for migraine prevention in the revised VA/DoD guideline
What the researchers found
The 2023 VA/DoD guideline incorporates CGRP inhibitors (gepants for acute treatment, CGRP monoclonal antibodies and atogepant for prevention) as recommended options for migraine management alongside traditional treatments.
Why it matters
Military and veteran populations have high rates of headache disorders. This guideline update reflects the clinical maturation of CGRP-targeting therapies and provides evidence-based direction for millions of patients in the VA/DoD healthcare system — and influences civilian practice as well.
The numbers in context
Revised in 2023, earlier than the standard 5-year cycle from the 2020 guideline.
How the study worked
Clinical practice guideline developed by VA/DoD subject matter experts based on systematic review of 5 databases (March 2019 - August 2022), with consensus recommendations considering evidence quality, patient preferences, and benefit-harm balance.
Who was studied
Clinical practice guideline for headache management in VA/DoD settings
What this study cannot tell us
Evidence review ended in August 2022, so very recent CGRP data may not be reflected. Guidelines are developed for VA/DoD populations, which skew male and may have different comorbidity profiles than the general population. Implementation and access to newer CGRP drugs may vary across VA facilities.
How to read the evidence
Strong evidence supporting the guideline — based on systematic review of published evidence with expert consensus. The underlying CGRP drug trials provide robust clinical data.
When this study was published
Published in 2024 (guideline revised in 2023). Reflects the most current VA/DoD clinical practice standards for headache management.
The bigger picture
The inclusion of CGRP-targeting therapies in major government clinical guidelines represents a milestone for this peptide-based drug class. It signals that CGRP inhibitors have moved from novel therapies to standard-of-care options, supported by sufficient evidence for broad clinical adoption.
Questions still open
- How does real-world CGRP inhibitor adoption in VA/DoD settings compare to civilian healthcare?
- Will the next guideline revision incorporate dual CGRP pathway targeting or newer agents?
- What are the cost-effectiveness implications of recommending CGRP drugs as frontline options?
Common questions
What's new about CGRP drugs in this guideline?
Does this guideline apply only to veterans?
Read the original research
2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache.
Annals of internal medicine, 177(12), 1675-1694
Citation
Sico, Jason J; Antonovich, Natasha M; Ballard-Hernandez, Jennifer; Buelt, Andrew C; Grinberg, Amy S; Macedo, Franz J; Pace, Ian W; Reston, James; Sall, James; Sandbrink, Friedhelm; Skop, Karen M; Stark, Thomas R; Vogsland, Rebecca; Wayman, Lisa; Ford, Aven W. (2024). 2023 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guideline for the Management of Headache.. Annals of internal medicine, 177(12), 1675-1694. https://doi.org/10.7326/ANNALS-24-00551