Equity of African American Men in Headache in the United States: A Perspective From African American Headache Medicine Specialists (Part 1).

Migraine and severe headache affect approximately 1 in 6 U.S. adults and migraine is one of the most disabling disorders worldwide. Approximately 903,000 to 1.5 million African American (AA) men are affected by migraine in the United States. Racial disparities in headache medicine exist. In addition, there are limited headache studies that attest to the inclusion of or have robust data on AA men in headache medicine in the United States. Racial concordance between provider and patient may ameliorate some aspects of care disparities. Moreover, it has been demonstrated that diversity and inclusion particularly in leadership of organizations has consistently produced positive change, increased innovation, and long-term success. Most national headache organizations strive to improve the care and lives of people living with headache disorders yet only ~0.5% of their physician members are AA men. Herein, we provide an observation of equity issues from the perspective of AA men in the headache medicine subspecialty. Part 1 of this manuscript explores inherent and potential challenges of the equity of AA men in headache medicine including headache disparities, mistrust, understudied/lack of representation in research, cultural differences, implicit/explicit bias, and the diversity tax. Part 2 of this work offers possible solutions to achieve equity for AA men in headache including: (1) addressing head and facial pain disparities and mistrust in AA men; (2) professionalism and inclusion; (3) organizational/departmental leadership buy-in for racial diversity; (4) implicit/explicit and other bias training; (5) diversity panels with open discussion; (6) addressing diversity tax; (7) senior mentorship; (8) increased opportunities for noteworthy and important roles; (9) forming and building alliances and partnerships; (10) diversity leadership training programs; (11) headache awareness, education, and literacy with focus to underrepresented in medicine trainees and institutions; and (12) focused and supported the recruitment of AA men into headache medicine. More work is needed for equity of AA men in headache medicine.

Equity of African American Men in Headache in the United States: A Perspective From African American Headache Medicine Specialists (Part 2).

In part 1 of this opinion piece, we described inherent and potential challenges of the equity of African American (AA) men in headache medicine including headache disparities, mistrust, understudied/lack of representation in research, cultural differences, implicit/explicit bias, and the diversity tax. We shared personal experiences related to headache medicine likely faced due to the color of our skin. In part 2, we offer possible solutions to achieve equity for AA men in headache including: (1) addressing head and facial pain disparities and mistrust in AA men; (2) professionalism and inclusion; (3) organizational/departmental leadership buy-in for racial diversity; (4) implicit/explicit and other bias training; (5) diversity panels with open discussion; (6) addressing diversity tax; (7) senior mentorship; (8) increased opportunities for noteworthy and important roles; (9) forming and building alliances and partnerships; (10) diversity leadership training programs; (11) headache awareness, education, and literacy with a focus to underrepresented in medicine trainees and institutions; and (12) focused and supported the recruitment of AA men into headache medicine.

Low-pressure/spinal fluid leak headache.

Low cerebrospinal fluid (CSF) pressure results in neurologic deficits, of which the most common manifestation is headache. Typically, the headache is postural - and specifically, orthostatic - in presentation. There are three hypotheses to explain the occurrence of headache associated with low CSF fluid. The first is traction on pain-sensitive intracranial and meningeal structures; the second is CSF hypovolemia; and the third is spinal loss of CSF resulting in increased compliance at the caudal end of the CSF space. Spontaneous intracranial hypotension (SIH), once believed to be rare, is now more commonly recognized. It is typically associated with orthostatic headache (although initially it may not be) and one or more other symptoms such as alterations in hearing, nausea, vomiting, neck stiffness, diplopia, and visual field cuts. Magnetic resonance imaging (MRI) of the brain with gadolinium is the first study of choice, which typically reveals diffuse pachymeningeal enhancement and, frequently, cerebellar tonsillar descent and posterior fossa crowding. Epidural blood patch (EBP) is the treatment of choice. Surgery and epidural fibrin glue injection are options for those who fail conservative therapy and/or EBP.

Is gabapentin an effective treatment choice for hemicrania continua?

The objective of this study is to examine the efficacy of gabapentin for the treatment of hemicrania continua (HC) in cases where patients had difficulty tolerating indomethacin due to adverse effects. A retrospective chart review of nine patients with HC between October 2006 and February 2008. Inclusion criteria included men and women age 18 or above presenting to the headache center with a headache that meets International Headache Society criteria for HC including a response to indomethacin, but were not able to continue on indomethacin secondary to adverse effects. Four patients report being pain free, three patients report a 50-80% reduction of pain, one patient reports a 10% reduction of pain, and one patient reports no change in pain. Seven out of nine patients demonstrated at least a 50% reduction of pain on gabapentin, four patients becoming completely pain free.

Acute treatment of migraine.

The goals of acute treatment of migraine are cost-effective rapid relief, consistent reduction of disability, and reduced use of rescue medications. Key to acute treatment is matching medication to disability as a surrogate marker for disease severity with a stratified care approach. In the absence of vascular contraindications, triptans are first-line acute treatments for disabling migraine. Acute treatment success can be assessed with use of the paper tool, Migraine-ACT. Opioids and butalbital should be avoided in acute migraine treatment. Triptan type can be selected for patients by differences in speed or effect, formulation, and formulary tier.

Hemicrania continua: a case in which a patient experienced complete relief on melatonin.

This paper reports a case of hemicrania continua in which attacks were successfully eliminated while taking melatonin 7 mg at bedtime after the patient was no longer able to tolerate indomethacin due to gastrointestinal side effects.

Hemicrania continua: a third case in which attacks alternate sides.

Hemicrania continua (HC) is an uncommon, primary headache disorder characterized by a continuous unilateral headache of moderate intensity with superimposed exacerbations of more severe pain. HC exists in two temporal subtypes, a continuous form in which headaches persist continuously without remission periods, and a less common remitting form in which bouts of continuous headaches are separated by pain-free remissions. There have been more than 100 prior reports of HC; in the majority of which the headache is strictly unilateral and without side shift. We now report the third patient in whom headaches alternated sides during different attacks.

Colloid cyst headache.

Colloid cysts of the third ventricle are rare intracranial tumors, accounting for 0.5% of intracranial tumors. Colloid cysts represent 2% of gliomas, are more common in men than women, and usually are diagnosed between the third and fifth decades of life. The primary presenting complaint of this disorder is headache. The headaches are described as intermittent, severe and intense, and of short duration and usually are located frontally. The main associated features are nausea and vomiting. The headache can be relieved by lying down, which is unusual for headaches secondary to intracranial tumors. Colloid cysts of the third ventricle are diagnosed by computed tomography or magnetic resonance imaging and treatment is surgical. This rare type of headache disorder is significant because it is associated with sudden death. Recognition of the unusual features of colloid cyst headache may result in decreased mortality in this disorder.