Migraine is one of the most common neurologic conditions, yet many people with migraines have difficulty getting care to reduce or prevent chronic headache. It has been estimated that in the US only about a quarter of adults with episodic migraine are able to get an accurate diagnosis and appropriate treatment. Part of the explanation for this may be healthcare disparities, defined as racial or ethnic differences that impact quality of care. Disparities are separate from, and not related to, access issues or clinical needs, preferences, and appropriateness of care.
Researchers have recently highlighted the issues that contribute to disparities within the healthcare system in the treatment of headache, and proposed some potential solutions. The authors reviewed the current research for evidence of disparities in headache care and found several, including those pertaining to race, socioeconomic status, insurance coverage, and geography.
Racial biases play a strong role in obtaining adequate headache care
Although the frequency of migraine among racial groups in the US is roughly equivalent, African American and Hispanic patients are, respectively, 25% and 50% less likely to be diagnosed with migraine compared to white patients. African American patients presenting to the emergency department appear to be almost five times less likely than white patients to receive diagnostic imaging. White children are three times more likely to receive imaging than children of other races. African Americans are less likely than white patients to utilize health care settings for migraine. They are also less likely to receive a headache diagnosis, and less likely to be prescribed migraine medication. Perhaps part of this is due to patients' distrust of providers and negative perception of the healthcare system.
The most pervasive inequity, according to the new research, was a bias against the use of pain medications in nonwhite populations, which leads to two opposing issues. On the one hand, less effective pain control in nonwhite populations can lead to poorer care and more disability; on the other hand, relative overprescription of inappropriate pain medications in the white population may expose them unnecessarily to possible dependence and abuse. Headache medicine disparities also exist for American Indian and Alaska Native patients, and headache medicine providers should be aware of the issue and work to reduce such disparities for all nonwhite groups.
Migraine prevalence is strongly connected to household income
Lower socioeconomic status is associated with a 60% higher rate of migraine. That means that, adding this issue to the issues previously mentioned, patients of color with low incomes are at twice the risk for health disparities. Additionally, a lack of access to health insurance can limit the ability of headache patients to obtain an appointment, and to receive an accurate diagnosis and up-to-date treatment.
Location and makeup of training programs add to disparities in headache care
Headache medicine fellowship programs, which train future headache specialists, are unevenly distributed throughout the US, mostly in urban areas in the Northeast and mid-Atlantic regions. In addition, these programs are not able to produce nearly enough specialists. Further, it is observed that fellowship-trained headache specialists tend to remain near to where they train. Finally, those trainees entering fellowships generally do not have a racial or ethnic makeup that matches the patient population they care for. These factors, most of which seem likely to persist, combine to produce geographic disparities that play a role in access to care. Further complicating geographic disparities, rural Americans tend to have lower median household incomes, lower levels of education, and reduced health literacy. Along with geographic issues such as longer travel distances for care, barriers to care in rural communities are compounded compared with urban communities.
Additional barriers for patients seeking treatment for headaches
Barriers and providers' lack of sensitivity or awareness may be an issue for LGBTQ patients, who may have specialized medical considerations. For example, people using hormonal therapy may experience migraine, and providers may be unfamiliar with this side effect, or may not ask about hormone treatments. Adverse childhood experiences, traditionally characterized as emotional, sexual, or physical abuse, are associated with a higher risk of migraine. More recently, the list of adverse experiences has been expanded to include such things as witnessing violence in the family, experiencing a divorce in the family, living in an unsafe neighborhood, and racism. Since communities of color often carry a disproportionately higher share of such burdens, the effect on the health of these populations is magnified.
Research in headaches is biased
For several reasons, including less emphasis on diverse recruitment efforts and potential language barriers, most of the current research done in migraine is with white females. Other racial groups may be wary of participating or may not even be asked to participate. The result is that it is less clear whether the findings of migraine studies would apply to other racial and ethnic groups.
Suggested solutions that can reduce disparities in headache care
- Improve patient and physician education about headache disorders, including how to access and advocate for care.
- Improve education for primary care providers in the management of headache disorders, especially in regions where there are fewer headache specialists.
- Advocate for structural and scalable changes designed to improve access to care, with innovations such as telemedicine to help remove travel barriers.
- Offer training to providers in implicit bias and cultural sensitivity and competence.
- Develop recruitment strategies to increase representation of underserved groups, both as headache medicine providers and as participants in headache research.