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Jung MJ, Kanegi SL, Rosen NL. Treating the Uninsured and Underinsured with Migraine in the USA. Curr Pain Headache Rep 2024; 28:133-139. [PMID: 38095749 DOI: 10.1007/s11916-023-01197-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/30/2023] [Indexed: 03/10/2024]
Abstract
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.
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Affiliation(s)
- Min J Jung
- Department of Neurology, Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, TX, USA
| | - Skyler L Kanegi
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Noah L Rosen
- Department of Neurology, Northwell Health Neuroscience Institute/Zucker School of Medicine at Hofstra University, 611 Northern Boulevard, Suite 150, Great Neck, NY, 11021, USA.
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Shapiro HFJ, Loder E, Shapiro DJ. Association between clinician specialty and prescription of preventive medication for young adults with migraine: A retrospective cohort study. Headache 2023; 63:1232-1239. [PMID: 37695270 DOI: 10.1111/head.14628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Revised: 08/09/2023] [Accepted: 08/14/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVE We aimed to compare the prescribing patterns of preventive medications between pediatric and adult neurologists for young adults with migraine. BACKGROUND Although preventive medications are effective for adults with migraine, studies in children have failed to demonstrate similar efficacy. As a result, lifestyle modifications and non-pharmacological interventions are often emphasized in children. It is not known whether young adults are prescribed preventive medications at different rates according to whether they are cared for by an adult or pediatric neurologist. METHODS We performed a multicenter retrospective cohort analysis of patients with migraine aged 18-25 years who were seen by a pediatric or adult neurologist at Mass General Brigham Hospital between 2017 and 2021. The primary outcome was whether the patient received a prescription for any preventive medication during the study period. RESULTS Among the 767 included patients, 290 (37.8%) were seen by a pediatric neurologist. Preventive medications were prescribed for 131/290 (45.2%; 95% confidence interval [CI]: 39.5%, 51.0%) patients seen by a pediatric neurologist and 206/477 (43.2%; 95% CI: 39.0%, 47.7%) patients seen by an adult neurologist (p = 0.591). In the mixed effects logistic regression model, clinician specialty was not associated with preventive medication use (adjusted odds ratio [AOR] 1.20, 95% CI: 0.62, 2.31). Female sex (AOR 1.69, 95% CI: 1.07, 2.66) and number of visits during the study period (AOR 1.64, 95% CI: 1.49, 1.80) were associated with receiving preventive medication. CONCLUSION Approximately two fifths of young adults with migraine were prescribed preventive medications, and this proportion did not differ according to clinician specialty. Although these findings suggest that pediatric and adult neurologists provide comparable care, both specialties may be underusing preventive medications in this patient population.
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Affiliation(s)
- Hannah F J Shapiro
- Department of Neurology, University of California, San Francisco, UCSF Benioff Children's Hospital, San Francisco, California, USA
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Elizabeth Loder
- Department of Neurology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Daniel J Shapiro
- Department of Emergency Medicine, University of California, San Francisco, San Francisco, California, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
- Department of Pediatrics, Boston Children's Hospital, Boston, Massachusetts, USA
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Gelfand AA, Allen IE, Grimes B, Irwin S, Qubty W, Greene K, Waung M, Powers SW, Szperka CL. Melatonin for migraine prevention in children and adolescents: A randomized, double-blind, placebo-controlled trial after single-blind placebo lead-in. Headache 2023; 63:1314-1326. [PMID: 37466211 DOI: 10.1111/head.14600] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2023] [Revised: 05/12/2023] [Accepted: 06/25/2023] [Indexed: 07/20/2023]
Abstract
BACKGROUND Melatonin is effective for migraine prevention in adults. We hypothesized that melatonin would also be effective for migraine prevention in children and adolescents. METHODS This was a randomized, double-blind trial of melatonin (3 mg or 6 mg) versus placebo for migraine prevention in 10-17 year-olds with 4-28/28 headache days at baseline. Participants were recruited from the UCSF Child & Adolescent Headache Program, UCSF child neurology clinic, and social media advertisements. Migraine diagnosis was confirmed by a headache specialist. Participants completed an 8-week single-blind placebo run-in. Those meeting randomization criteria (≥4 headache days and ≥23/28 electronic diary entries during weeks 5-8) were randomized 1:1:1 to placebo:melatonin 3 mg:melatonin 6 mg nightly for 8 weeks. The primary outcome measure was migraine days in weeks 5-8 of randomized treatment between melatonin (combined 6 mg + 3 mg) versus placebo. We aimed to enroll n = 210. RESULTS The study closed early due to slow enrollment (n = 72). Two participants were in the single-blind phase when the study closed, therefore the meaningful n = 70. Sixteen percent (11/70) were lost to follow-up during the single-blind phase. An additional 21% (15/70) did not meet randomization criteria (<4 headache days: n = 5, <23/28 diary days: n = 7, both: n = 3). Sixty-three percent (44/70) were eligible to randomize, of whom 42 randomized (n = 14 per arm). Taking another preventive at enrollment (OR 8.3, 95% CI 1.01 to 68.9) was the only variable associated with meeting randomization criteria. Of those randomized, 91% (38/42) provided diary data in the final 4-weeks. However, given the amount of missing data, only those with ≥21/28 diary days were analyzed-7/14 (50%) in the placebo group, and 20/28 (71%) in the melatonin groups combined. Median (IQR) migraine/migrainous days in weeks 5-8 of double-blind treatment was 2 (1-7) in the placebo group versus 2 (1-12) in the melatonin groups combined; the difference in medians (95% CI for the difference) was 0 days (-9 to 3). There were no differences in adverse events between groups. CONCLUSIONS When compared to recall at enrollment, headache days decreased across the single-blind placebo phase and the double-blind phase. There was no suggestion of superiority of melatonin; however, given the substantial portion of missing data, numerically higher in the placebo arm, and underpowering, this should not be interpreted as proof of inefficacy. Melatonin was generally well tolerated with no serious adverse events. Future migraine preventive trials in this age group may find this trial helpful for anticipating enrollment needs if using a single-blind placebo run-in. Enriching for those already on a migraine preventive may improve randomization rates in future trials, though would change the generalizability of results.
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Affiliation(s)
- Amy A Gelfand
- Child & Adolescent Headache Program, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - I Elaine Allen
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Barbara Grimes
- Department of Epidemiology & Biostatistics, University of California San Francisco, San Francisco, California, USA
| | - Samantha Irwin
- Child & Adolescent Headache Program, University of California San Francisco, San Francisco, California, USA
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - William Qubty
- Minneapolis Clinic of Neurology, Minneapolis, Minnesota, USA
| | - Kaitlin Greene
- Department of Pediatrics, Oregon Health Sciences University, Portland, Oregon, USA
| | - Maggie Waung
- Department of Neurology, University of California San Francisco, San Francisco, California, USA
| | - Scott W Powers
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio, USA
- Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
- Headache Center, Cincinnati Children's Hospital, Cincinnati, Ohio, USA
| | - Christina L Szperka
- Pediatric Headache Program, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Govil-Dalela T, Thomas R, Weber A, Kamat D, Williams MT, Przyklenk K, Sivaswamy L. Pediatric Resident Confidence in Assessing Neurological Cases: A Nationwide Survey. Pediatr Neurol 2023; 145:57-66. [PMID: 37279616 DOI: 10.1016/j.pediatrneurol.2023.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 02/16/2023] [Accepted: 05/07/2023] [Indexed: 06/08/2023]
Abstract
BACKGROUND A relative shortage of pediatric neurologists in proportion to estimated neurological disorders often results in general pediatricians evaluating and treating children with complex neurological conditions. Dedicated rotations in pediatric neurology are not mandated during medical school or pediatric residency. We evaluated the perceptions of a large cohort of pediatric residents and program directors (PDs) regarding child neurology training. METHODS Using an online tool, surveys were sent to pediatric residents and pediatric and pediatric neurology PDs. RESULTS Response rates were 41% from pediatric residency programs, yielding 538 resident responses; 31% from pediatric PDs; and 62% from pediatric neurology PDs. Only 27% of the surveyed residents reported completing a neurology rotation during residency, 89% of whom expressed a subjective improvement in confidence with neurological assessments. Factors affecting comfort with eliciting a neurological history included exposure to a neurology rotation during residency, year of training, duration of neurology rotation in medical school, and inpatient exposure to neurological patients, whereas those associated with examination additionally included program size and postresidency plans. Overall, 80% of surveyed residents, 78% of pediatric PDs, and 96% of pediatric neurology PDs acknowledged the potential value of a mandatory pediatric neurology rotation during residency. CONCLUSION We suggest that a mandatory pediatric neurology rotation will boost the confidence of current and future pediatric trainees in assessing common neurological conditions of childhood.
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Affiliation(s)
- Tuhina Govil-Dalela
- Chief Resident in the Department of Pediatrics, Division of Neurology, Children's Hospital of Michigan, Detroit, Michigan
| | - Ronald Thomas
- Senior Biostatistician in the Department of Pediatrics, Central Michigan University and Clinical Research Institute, Children's Hospital of Michigan, Detroit, Michigan
| | - Amanda Weber
- Assistant Professor in the Department of Pediatrics, Division of Neurology, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan
| | - Deepak Kamat
- Professor and Vice-Chair for Academic Affairs in the Department of Pediatrics, UT Health San Antonio, San Antonio, Texas
| | - Mitchel T Williams
- Assistant Professor in the Department of Pediatrics, Division of Neurology, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan
| | - Karin Przyklenk
- Professor and Carman and Ann Adams Endowed Chair in Pediatric Research, Department of Pediatrics, Central Michigan University and Clinical Research Institute, Children's Hospital of Michigan, Detroit, Michigan
| | - Lalitha Sivaswamy
- Professor and Division Chief in the Department of Pediatrics, Division of Neurology, Central Michigan University and Children's Hospital of Michigan, Detroit, Michigan.
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Kanegi SL, Rosen NL. Ahead of the pain: Where we stand after a decade of growth in United Council for Neurologic Subspecialties-certified headache subspecialists. Headache 2022; 62:1339-1353. [PMID: 36416481 DOI: 10.1111/head.14425] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Revised: 09/25/2022] [Accepted: 09/26/2022] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Skyler L Kanegi
- Long School of Medicine, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Noah L Rosen
- Northwell Health Neuroscience Institute/Zucker School of Medicine, Hofstra University, Great Neck, New York, USA
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Abstract
PURPOSE OF REVIEW This article reviews the approach to a child or adolescent with headache, the criteria for common diagnoses, and the evidence base for treatments. RECENT FINDINGS The guidelines for acute and preventive treatment of migraine were updated in 2019. These guidelines summarize the available evidence and outline the questions that should be addressed in future research. The US Food and Drug Administration (FDA) approval of several new classes of drugs and devices to treat adult migraine in the past few years has resulted in ongoing or planned pediatric trials. SUMMARY Headache is a common symptom in children, and it is important to take a detailed history and perform a thorough physical examination to make the diagnosis. Nearly 1 in 10 children experience recurrent headaches due to migraine, which cause significant impairment in school performance and quality of life. The acute and preventive treatments that are currently available will help at least two-thirds of children with migraine, and several trials of new therapies offer hope for the future.
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