The Migraine Treatment Journey in US Veterans: A National Cohort Study of Prescribing Patterns

Migraine in veterans is poorly understood due to limited real-world treatment data. This study aimed to characterize pharmacotherapeutic pathways for US veterans with migraine and evaluate the impact of care setting on therapy progression. This was a national, population-based, retrospective cohort study utilizing deidentified electronic health record data between January 2019 and June 2024 extracted from the Veterans Affairs Corporate Data Warehouse. Eligible patients were aged > 18 years with at least one diagnosis of migraine (ICD-10: G43.x) or one migraine-specific medication. The primary objective was to describe treatment patterns for veterans. Differences between primary care (PC) and specialty care (SC) were assessed using subdistribution hazard ratios (sHR). Of 285,509 patients with newly diagnosed migraine, 252,661 (88.5%) received pharmacologic treatment and 150,684 (59.6%) received ≥ 1 preventive medication. The median (25th–75th percentile) number of treatment sequence steps was two (1–2), with a median time of 3 (0–40) days between diagnosis and initial treatment steps and 72 (5–295) days between subsequent treatment steps. For patients who received preventive medication, the median number of treatment sequence steps was one (1–2), with a median time from diagnosis to initial treatment steps of 46 (5–225) days and 128 (28–418) days between subsequent treatment steps. Of patients who received preventive medications, 91,793 (60.9%) received care from a PC provider only, and 21,268 (14.1%) from a SC provider only. Veterans receiving care within SC settings were > 50% more likely to transition to a second sequential step of preventive treatment (sHR 1.54 [95% CI 1.51–1.58]) and > six times more likely to initiate preventive calcitonin gene-related peptide (CGRP) antagonists (sHR 6.43 [95% CI 5.94–6.97]). Most veterans with migraine received pharmacologic treatment. Intervals for initiating and transitioning preventive therapies were longer than recommended by guidelines. Veterans under SC were more likely to progress through preventive therapies, including CGRP antagonists, than those in PC.