Treating the Uninsured and Underinsured with Migraine in the USA.

PURPOSE OF REVIEW: To define, describe, and identify potential solutions for health disparities in the uninsured and underinsured with migraine in the USA. RECENT FINDINGS: Uninsured and underinsured patients with migraine experience health disparities in diagnosis and treatment of migraine. Migraine patients have higher healthcare costs and higher employment disability, which contribute to a higher likelihood of uninsured or underinsured status. Uninsured or underinsured status, combined with factors such as race, socioeconomic status, geographic location, and care location, are correlated with delays in or decreased migraine diagnosis and treatment. Migraine prevalence is increased in the uninsured and underinsured. Potential solutions include advocacy for policy changes that improve access to care, increasing awareness and representation of underrepresented groups, providing resources to patients to reduce costs, and active patient engagement in migraine care. Continued efforts from all stakeholders have the potential to reduce health disparities in uninsured and underinsured patients with migraine, reducing disability and improving quality of life.

Ahead of the pain: Where we stand after a decade of growth in United Council for Neurologic Subspecialties-certified headache subspecialists.

OBJECTIVE: To characterize the geographic distribution of United States (US) headache subspecialists in 2021 compared to 2012 and analyze trends in distribution of and growth by geography. INTRODUCTION: Headache disorders are the second-highest cause of disease burden worldwide. Historically, headache disorders have been treated by primary care and emergency physicians, often suboptimally. Our 2012 study identified further disparities in geographic distribution of United Council for Neurologic Subspecialties (UCNS)-certified headache subspecialists. METHODS: This correlational population study explores the current geographic distribution of and changes in subspecialists by aggregating data from the UCNS, National Health Interview Survey, US Census, Bureau of Economic Analysis, and American Community Survey. RESULTS: In 2021, there were 692 UCNS-certified headache subspecialists. There continued to be higher subspecialist density in the Northeast (1:34,678) and Midwest (1:55,005), with the highest density in Vermont (1:12,510) and Connecticut (1:20,419). The highest absolute subspecialist increases were in the South (99), California (35), and Texas (25). The highest relative subspecialist increases were in the West (105%), Vermont (500%), and Mississippi (500%). The univariable regressions showed significant associations between number of subspecialists and adult headache population (R2  = 0.797, p < 0.001), between subspecialist density and personal income (R2  = 0.935, p = 0.033), and between growth in subspecialists and poverty rate (R2  = 0.553, p = 0.022). However, the multivariable regressions showed that only the adult population was significantly associated with number of subspecialists (adjusted R2  = 0.806, p < 0.001). CONCLUSION: Overall, there has been substantial growth in the number of UCNS-certified headache subspecialists in the US, especially relative to growth in adult headache population. Subspecialist density continues to be highest in the Northeast and is associated with higher per capita personal income. However, there has been encouraging growth in geographies that previously had little to no access. These findings represent positive progress, but there is more to be done to both increase access to optimal headache care by subspecialists nationally and decrease geographic disparities in access to care.

Cogniphobia and neuropsychological functioning in migraine.

OBJECTIVE: Cogniphobia refers to the fear and avoidance of cognitive exertion, believed to cause or exacerbate headache. The objective of the present study was to demonstrate associations between cogniphobia and key fear-avoidance constructs. METHOD: In this cross-sectional study, 72 adults with migraine were recruited from a tertiary headache center. Patients completed the Cogniphobia Scale for Headache Disorders (CS-HD) and a series of self-reported surveys and neuropsychological measures that assessed patient demographics, migraine diagnosis and headache characteristics, current pain severity, emotional state (i.e., anxiety, pain-related fear, and depression), cognitive exertion, and functioning (self-reported disability, self-reported cognitive symptoms, and neuropsychological measures). RESULTS: The CS-HD was associated with greater anxiety (Patient-Reported Outcomes Measurement Information System; PROMIS Anxiety; r = 0.39, p = .001), pain-related fear (PASS-20; ρ = 0.37, p = .002), self-reported cognitive symptoms (ABS; ρ = 0.38, p = .001), self-reported headache disability (HDI; r = 0.28, p = .022), and depression (PROMIS Depression; r = 0.25, p = .039). The CS-HD was also associated with lower scores on neuropsychological measures of semantic fluency (Animal Naming; r = -0.29, p = .015), visual immediate recall memory (RCFT Immediate Recall; r = -0.27, p = .027), visual delayed recall memory (RCFT Delayed Recall; r = -0.36, p = .002), and visual recognition memory (RCFT Recognition; r = -0.42, p < .001), with comparable findings when adjusting for depression and anxiety. CONCLUSION: This study demonstrated associations between cogniphobia and key fear-avoidance constructs. Fear-avoidance constructs, such as cogniphobia, are important constructs to consider when evaluating migraine and neuropsychological functioning. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

The current state of headache medicine education in the United States and Canada: An observational, survey-based study of neurology clerkship directors and curriculum deans.

OBJECTIVE: To investigate the current headache medicine education paradigm in allopathic and osteopathic medical schools in the United States and Canada. BACKGROUND: There is a disparity in the number of clinicians specially trained to treat patients with headache disorders and the number of people who have them. Early education and exposure to headache medicine is crucial to address this disparity. However, the current state of headache education within medical schools across the United States and Canada is unknown. METHODS: The authors created a medical student headache education survey, which is a 20-question REDCap survey that was distributed via email to the neurology clerkship director, curriculum dean, or similar role at each US and Canadian MD or DO conferring medical school. The email listserv was created using the American Academy of Neurology Clerkship Directory, the Association of American Medical Colleges Organization Directory, the American Association of College of Osteopathic Medicine Organization Directory, manual searches of the institutions' websites, and phone calls and emails to administrators as needed. RESULTS: Of the 249 individuals contacted, 78 completed the survey, yielding a response rate of 31.3%. Of those responses, 84.6% of respondents (66/78) reported that their institution has at least one mandatory session on headache disorders. Many of these sessions (72.7% (48/78)) occurred during preclinical training, and 74.2% (49/78) occurred as part of the clinical curricula. Of respondents, 44.9% (39/78) reported that their institutions coordinate headache education across training levels (i.e., from preclinical to clinical), and only 17.9% (14/78) coordinate across clinical rotations. The most common topics covered were headache red flags, migraine, pharmacologic management, and differentiating primary versus secondary headache. 65.4% of respondents (51/78) felt that the preclinical headache curriculum prepares their students for the clinical experience, and 55.1% (43/78) felt that medical students were learning enough about headache medicine at their institution. Barriers to educating medical students about headache included insufficient time during courses, lack of administrative support in curricula development, lack of available resources, and lack of student interest. Case-based learning modules and online lectures were the most desired educational materials to improve medical student headache education at their institution. CONCLUSIONS: The majority of medical schools report incorporating headache medicine education into preclinical or clinical curricula and cover a range of topics in headache medicine. Yet there remains a lack of consistency, with some reporting limited headache education, citing barriers such as lack of administrative support and available educational resources. There is also variation in what is being taught at the medical student level. Future projects should aim to address said barriers, with the goal of providing a standardized headache medicine curriculum for use across medical schools.

Grand rounds education in neurology, with a focus on headache medicine.

OBJECTIVE: To quantify the proportion of headache-related grand rounds in academic neurology programs and to compare this with adult neurology residency director views on the need for an increase in headache-related grand rounds. BACKGROUND: Although headache are among the most prevalent and most burdensome neurologic conditions, headache medicine is often considered underrepresented in neurology departments. Additionally, prior studies have shown that many neurology residency directors feel that training programs do not include an adequate amount of exposure to headache clinics or headache-related didactics. One important aspect of didactic education in neurology departments is adult neurology grand rounds. Previous publications have evaluated neither the proportion of headache-related grand rounds in academic neurology departments nor the residency program directors' views on appropriate amount of headache-related grand rounds. Our study has attempted to quantify this information to elucidate opportunities to improve practice educational gaps. METHODS: In this cross-sectional study, we surveyed adult neurology residency directors (from the Accreditation Council for Graduate Medical Education [ACGME] listing of academic adult neurology residency programs) between October 2018 and September 2019. In addition, we used two methods to obtain the proportion of headache-related grand rounds in neurology: (1) emailing residency directors a questionnaire asking for a list of prior grand rounds topics and (2) an online search for each academic neurology program. RESULTS: First, for our grand rounds analysis, headache medicine consisted of 3.7% of the lectures in 2017-2018 and 6.3% of the lectures in 2018-2019 (average of each institution; 17 institutions and 411 total lectures in 2017-2018, 21 institutions and 463 total lectures in 2018-2019). The most common number of lectures on headache medicine for each grand rounds series was zero (for 7 of 17 grand rounds series in 2017-2018 and 7 of 21 in 2018-2019), followed closely by one lecture (for 6 of 17 grand rounds series in 2017-2018 and 6 of 21 in 2018-2019). Second, for our survey, the response rate was 19.3% (29/150). No residency director thought their institution had too many grand rounds dedicated to headache medicine, and 62.1% (18/29) thought they had an adequate amount of headache grand rounds. Within the survey responders, 75.9% (22/29) of adult neurology residency programs have a board-certified headache specialist at their institution. CONCLUSIONS: Although most adult neurology residency directors believe that headache is adequately represented in adult neurology grand rounds, headache medicine makes up 4%-6% of all neurology grand rounds. Compared with other neurology subspecialties and the other core ACGME milestones, headache makes up the fewest grand rounds lectures that were assessed in this study.

Incorporating Remote Electrical Neuromodulation (REN) Into Usual Care Reduces Acute Migraine Medication Use: An Open-Label Extension Study.

Background: A recent randomized controlled study showed that 66.7% (66/99) and 37.4% (37/99) of people undergoing remote electrical neuromodulation (REN), a novel non-pharmacological migraine treatment, achieve pain relief and pain freedom, respectively, at 2 h post-treatment. The participants who completed the 6-weeks double-blind phase of this study were offered to participate in an open-label extension (OLE) with an active REN device. Objective: This study investigated the clinical use of REN, focusing on its potential in reducing the use of acute migraine medications. Methods: The parent study for this open-label extension (OLE) was a randomized, double-blind, sham-controlled study of acute treatment conducted on 296 participants enrolled at 12 sites in the USA and Israel. This study included a run-in phase, in which migraine attacks were treated with usual care, and an 8-weeks double-blind treatment phase. One hundred sixty participants continued in an 8-weeks OLE phase in which they could incorporate a REN device into their usual care. Medication use rate (percentage of participants who treated their attacks only with REN and avoided medications in all their attacks) and pain outcomes at 2 h post-treatment were compared between the OLE and the run-in phase in a within-subject design. Results: The analyses were performed on 117 participants with episodic migraine. During the OLE, 89.7% of the participants treated their attacks only with REN and avoided medications in all their attacks compared with 15.4% in the run-in phase (p < 0.0001). The rates of pain relief and pain-free in at least 50% of the treatments at 2 h post-treatment were comparable (pain relief: 58.1% in the run-in phase and 57.3% in the OLE, p = 0.999; pain-free: 23.1% in the run-in vs. 30.8% in the OLE, p = 0.175). Conclusions: REN may reduce the use of acute migraine medications. Thus, incorporating REN into usual care may reduce the risk for medication overuse headache (MOH). Future studies should evaluate whether REN reduces the use of acute migraine medications in a population at risk for MOH.

The Influence of Migraine on Driving: Current Understanding, Future Directions, and Potential Implications of Findings.

OBJECTIVE: To review the published findings relevant to migraine and driving performance, with an intent to encourage discussion on research which may broaden understanding in this area and help educate healthcare providers and their patients. BACKGROUND: Motor vehicle crashes result in more than 35,000 deaths and more than 2 million injuries annually in the United States. Migraine is one of the most prevalent diseases in the world, and many symptoms associated with migraine attacks have the potential to negatively influence driving ability. METHODS: We reviewed the published findings related to migraine and driving performance. Study findings relevant to symptoms of migraine and their potential effect on driving were also reviewed. This required a more expansive exploration of the literature beyond migraine, for example, review of the literature relating to the effect of pain, sleepiness, visual disturbances, or vertigo on driving. Finally, the potential effects of treatment for migraine on driving were reviewed. RESULTS: Literature on the effect of migraine on driving performance is sparse and, in general published studies on the topic have a number of limitations. Based on review of the literature pertaining to other disorders, it seems feasible that some symptoms occurring as part of the migraine attack could impact driving performance, although formal study in this area is lacking. Many of the approved treatments for migraine have the potential to impact driving, yet this has not been specifically studied, and the extent to which these risks are communicated to patients is not clear. CONCLUSION: The impact of migraine on driving performance has been largely neglected, with few studies specifically designed to address the topic, and relevant studies were generally small with limited control of confounders. This area requires more focus, given a potential for impact on road safety.

Headache Interest in Academic Neurology Leadership: A Cross-Sectional Study.

BACKGROUND: Headache disorders are exceedingly common, debilitating neurological conditions, and there is a striking paucity of headache specialists nationally. However, headache education is underrepresented in the curriculum of neurology residency programs and few neurology residents elect to pursue headache medicine fellowships. We aimed to explore the possibility that a low degree of headache interest among neurology department chairs and residency program directors (PDs) underlies this mismatch. METHODS: We performed a cross-sectional analysis of chairs and PDs associated with ACGME neurology residency programs. Data sources included the ACGME program list, faculty profiles on institutional webpages, Doximity profiles, the American Headache Society (AHS) membership directory, and the roster of United Council for Neurologic Specialties (UCNS) headache diplomates. A headache interest was deemed to be present with the presence of a declared headache or concussion interest, completion of a headache fellowship, active AHS membership, or UCNS certification. RESULTS: Our review included 137 residency programs comprising 127 department chairs, 132 PDs, and 5 faculty who were both chairs and PDs. Of all faculty, 62 (23.5%) were women. Headache expertise was declared by 10 (7.6%) chairs and 13 (9.5%) PDs. Headache fellowship training was pursued by 1 (0.8%) chair and 5 (3.6%) PDs, and among all faculty was the 10th most common subspecialty fellowship pursued. Three (2.3%) chairs and 7 (5.1%) PDs were AHS members. Seven (5.3%) chairs and 10 (7.3%) PDs were UCNS headache certified. An overall headache interest was present in 29 (11.0%) faculty, including 14 (10.6%) chairs and 15 (10.9%) PDs. A graduate degree aside from an MD (eg, PhD, MPH) was more likely to be achieved in faculty without a headache interest (29.4%) than faculty with a headache interest (6.9%, P = .0076). Residency programs where either the chair or PD had a headache interest were just as likely to feature a UCNS headache fellowship program than programs without chair or PD headache interest (25.0 vs 23.0%, P = .83). CONCLUSIONS: Current neurology department chairs and residency PDs have low rates of headache interest, which may influence the emphasis of headache education in neurology training. Headache interest is associated with lower rates of other graduate degrees, and future analysis should examine if academic faculty interested in headache are less likely to be in leadership positions because of a lack of research funding, opportunities, or accomplishments.

OnabotulinumtoxinA improves quality of life and reduces impact of chronic migraine over one year of treatment: Pooled results from the PREEMPT randomized clinical trial program.

BACKGROUND: Chronic migraine (CM) is associated with high impact and reduced health-related quality of life (HRQoL). METHODS: Patients with CM from PREEMPT (Phase 3 REsearch Evaluating Migraine Prophylaxis Therapy) were randomized (1:1) to receive onabotulinumtoxinA or placebo for two 12-week cycles in the double-blind (DB) phase, followed by three 12-week cycles of open-label (OL) onabotulinumtoxinA (onabotulinumtoxinA/onabotulinumtoxinA (O/O) and placebo/onabotulinumtoxinA (P/O) groups, respectively). HRQoL endpoints were assessed over 56 weeks using the Headache Impact Test (HIT-6) and the Migraine-Specific Quality of Life Questionnaire (MSQ). HIT-6 score reductions ≥2.3 and ≥5 denoted between-group minimally important difference and within-patient clinically meaningful response, respectively. RESULTS: A total of 1236 participants (O/O, n = 607; P/O, n = 629) participated in both phases. The DB phase showed significantly reduced HIT-6 and MSQ for onabotulinumtoxinA versus placebo (all p < 0.001). The OL phase showed significantly reduced HIT-6 for O/O versus P/O at weeks 28, 36, and 48, but not 56. All three MSQ domains showed improved HRQoL relative to baseline, but only the role restrictive domain showed a significant difference between O/O and P/O at week 56. CONCLUSIONS: Benefits of onabotulinumtoxinA on HRQoL versus baseline persisted throughout the OL phase. Statistical superiority in favor of O/O was demonstrated for HIT-6 through 48 weeks and for MSQ (role restrictive) at 56 weeks.

The Sphenopalatine Ganglion: Anatomy, Pathophysiology, and Therapeutic Targeting in Headache.

The sphenopalatine ganglion (SPG) has attracted the interest of practitioners treating head and face pain for over a century because of its anatomical connections and role in the trigemino-autonomic reflex. In this review, we discuss the anatomy of the SPG, as well as what is known about its role in the pathophysiology of headache disorders, including cluster headache and migraine. We then address various therapies that target the SPG, including intranasal medication delivery, new SPG blocking catheter devices, neurostimulation, chemical neurolysis, and ablation procedures.

Comparative effectiveness of onabotulinumtoxinA versus oral migraine prophylactic medications on headache-related resource utilization in the management of chronic migraine: Retrospective analysis of a US-based insurance claims database.

BACKGROUND: Migraine, especially chronic migraine (CM), causes substantial disability; however, health care utilization has not been well characterized among patients receiving different migraine prophylactic treatments. METHODS: Using a large, US-based, health care claims database, headache-related health care utilization was evaluated among adults with CM treated with onabotulinumtoxinA or oral migraine prophylactic medications (OMPMs). Headache-related health care utilization was assessed at six, nine, and 12 months pre- and post-treatment. The primary endpoint was the difference between pre- and post-index headache-related health care utilization. A logistic regression model was created to test the difference between onabotulinumtoxinA and OMPM-treated groups for headache-related emergency department (ED) visits and hospitalizations. RESULTS: Baseline characteristics were comparable between groups. The proportion of patients with ED visits or hospitalizations for a headache-related event decreased after starting onabotulinumtoxinA, but increased after starting an OMPM, for all three cohorts. Regression analyses showed that the odds of having a headache-related ED visit were 21%, 20%, and 19% lower and hospitalization were 47%, 48%, and 56% lower for the onabotulinumtoxinA group compared to the OMPM group for the six-month, nine-month, and 12-month post-index periods, respectively. CONCLUSIONS: When compared with similar patients who initiated treatment with OMPM, onabotulinumtoxinA was associated with a significantly lower likelihood of headache-related ED visits and hospitalizations.

So many migraines, so few subspecialists: analysis of the geographic location of United Council for Neurologic Subspecialties (UCNS) certified headache subspecialists compared to United States headache demographics.

OBJECTIVE: To evaluate the geographic location of the United Council for Neurologic Subspecialties (UCNS)-certified headache subspecialists as compared with ratios of expected migraine and chronic migraine populations in the United States. BACKGROUND: The UCNS is a professional medical organization that accredits fellowship programs and certifies physicians who demonstrate competence in various neurologic subspecialties, including headache medicine. There are a limited number of UCNS-certified headache subspecialists currently practicing in the United States. METHODS: All of the UCNS-certified headache subspecialists were geographically located and compared with demographic data about state populations obtained from the U.S. Census. The expected migraine and chronic migraine populations were calculated for each state based on recently published epidemiologic data. Ratios of UCNS-certified headache subspecialists to expected migraine and chronic migraine populations were compared for each state. These data were then organized by U.S. Census region and division. RESULTS: As of the 2012 examination cycle, 416 UCNS-certified headache subspecialists are currently practicing in the United States. The states with the highest number of headache subspecialists include New York, California, Ohio, Texas, Florida, and Pennsylvania. Six states have zero headache subspecialists, eight states have one headache subspecialist, and five states have two headache subspecialists. As per the U.S. Census, the total U.S. population for ages 12 years and older is 259,908,563. The total expected migraine population (11.79% of the general population) for ages 12 years and older is 30,594,362. The total expected chronic migraine population (0.91% of the general population) for ages 12 years and older is 2,361,397. The states with the best ratios of headache subspecialists to expected migraine and chronic migraine populations include the District of Columbia, New Hampshire, New York, and Nebraska. Besides states with zero headache subspecialists, the states with the worst ratios of headache subspecialists to expected migraine and chronic migraine populations include Oregon, Mississippi, Arkansas, and Kansas. When organized by U.S. Census regions, the Northeast has the best ratios of headache subspecialists to expected migraine and chronic migraine populations, while the West has the worst ratios of headache subspecialists to expected migraine and chronic migraine populations. In terms of U.S. Census divisions, the Middle Atlantic has the best ratios of headache subspecialists to expected migraine and chronic migraine populations, while the East South Central has the worst ratios of expected migraine and chronic migraine populations. CONCLUSIONS: There is a disproportionately small number of UCNS-certified headache subspecialists compared with the extensive expected migraine and chronic migraine populations in the United States. More UCNS-accredited fellowship programs and more UCNS-certified headache subspecialists are needed in order to ameliorate this disparity.

Psychological issues in the evaluation and treatment of tension-type headache.

Tension-type headache is the most common headache disorder, affecting approximately 40 % of Americans within a one-year span. Although the most common form, episodic tension-type headache, is rarely impairing, more frequent tension-type headache can occur with significant disability and psychological comorbidity. Appreciating the psychological impact, assessing the associated biopsychosocial issues, and understanding patients' coping styles are important in forming an appropriate treatment plan and maximizing treatment outcomes. A range of psychological therapies including relaxation training, cognitive behavioral therapy, biofeedback and mindfulness have demonstrated utility in treating chronic pain conditions and reducing the associated disability. This may be particularly applicable to special populations, including pediatric patients, pregnant patients and geriatric. Psychological assessment and treatment may be done conjointly with medication management and expands treatment options. There is great need to continue researching the effects of psychological treatments, standardizing interventions and making them available to the wider population.

Psychological issues in the evaluation and treatment of tension-type headache.

Tension-type headache (TTH) is a common disease that is usually minimally impairing. However, more chronic TTH can be associated with significant disability and psychological comorbidity. Psychological assessment can help elucidate the biopsychosocial issues that complicate TTH and reveal the patient's coping styles. Psychological therapies, such as relaxation training, cognitive behavioral therapy, and biofeedback, may be helpful in reducing the frequency of TTHs and decrease the associated disability. Special populations, including pediatric patients, pregnant patients, and geriatric patients, may especially benefit from psychological interventions. Further work needs to be done in researching the effects of psychological treatments and making them available to a wider population.