Whites and African-Americans in Headache Specialty Clinics Respond Equally Well to Treatment

Diversity, Equity, and Inclusion in Headache Care and Research

ABSTRACT

This article reviews the disparities faced by individuals who experience headache disorders and discusses potential solutions to deliver equitable care. Disparities exist in the diagnosis and treatment of headache disorders with regard to race, ethnicity, sex, gender, sexual orientation, geography, and socioeconomic status. Furthermore, research in the realm of headache disparities is inadequate, and the clinical trial representation of patients from underserved communities is poor. Many barriers exist to optimizing care for underserved communities and this article addresses these barriers and presents ways to combat them.

Migraine history and response to lasmiditan across racial and ethnic groups

OBJECTIVE

The robust enrollment in SPARTAN and SAMURAI provided the opportunity to present post-hoc descriptive details on migraine disease characteristics and treatment outcomes after treatment with lasmiditan, a selective serotonin (5-HT_1F) receptor agonist, in racial and ethnic subgroups.

METHODS

Descriptive data from racial (White [W](n = 3471) and Black or African American [AA](n = 792)) and ethnic (Hispanic or Latinx [HL](n = 775) and Non-Hispanic or Latinx [Non-HL](n = 3637)) populations are presented on pooled data from two double-blind, placebo-controlled, randomized Phase 3 studies (SAMURAI [NCT02439320] and SPARTAN [NCT2605174]). Patients were treated with lasmiditan (50 (SPARTAN only), 100, or 200 mg) or placebo for a single migraine attack of moderate-to-severe intensity. Efficacy data were recorded in an electronic diary at baseline, 30, 60, 90, and 120 min. Safety was evaluated and reported by occurrences of adverse events.

RESULTS

Clinical characteristics were generally similar across populations. W participants had longer migraine history than AA participants, and Non-HL participants had more migraine disability than HL participants. In the lasmiditan single-attack studies, AA participants waited longer than W participants to take study drug. A higher proportion of HL participants rated baseline migraine severity as severe compared to Non-HL participants. Response to lasmiditan was similar across racial and ethnic groups, including pain response, freedom from most bothersome symptom and migraine-related disability, and safety and tolerability. Across multiple outcomes, AA and HL participants tended to report more positive outcomes.

CONCLUSIONS

There were few differences in demographic and clinical characteristics across racial and ethnic groups. Similar lasmiditan efficacy and safety outcomes were observed in AA versus W participants, and in HL versus Non-HL participants. Small observed differences may be driven by a tendency toward a more positive response observed across all treatment groups by AA and HL participants.

Factors Associated With, and Mitigation Strategies for, Health Care Disparities Faced by Patients With Headache Disorders

OBJECTIVE

To review contemporary issues of health care disparities in headache medicine with regard to race/ethnicity, socioeconomic status (SES), and geography and propose solutions for addressing these disparities.

METHODS

An Internet and PubMed search was performed and literature was reviewed for key concepts underpinning disparities in headache medicine. Content was refined to areas most salient to our goal of informing the provision of equitable care in headache treatment through discussions with a group of 16 experts from a range of headache subspecialties.

RESULTS

Taken together, a multitude of factors, including racism, SES, insurance status, and geographical disparities, contribute to the inequities that exist within the health care system when treating headache disorders. Interventions such as improving public education, advocacy, optimizing telemedicine, engaging in community outreach to educate primary care providers, training providers in cultural sensitivity and competence and implicit bias, addressing health literacy, and developing recruitment strategies to increase representation of underserved groups within headache research are proposed as solutions to ameliorate disparities.

CONCLUSION

Neurologists have a responsibility to provide and deliver equitable care to all. It is important that disparities in the management of headache disorders are identified and addressed.

Headache Disparities in African-Americans in the United States: A Narrative Review

OBJECTIVE

The goal of this paper is to give a narrative review of the racial/ethnic disparities in African-Americans (AA) found in headache medicine and provide plausible responses to the National Institute of Neurological Disorders and Stroke (NINDS) issued Request for information (RFI); "Soliciting Input on Areas of Health Disparities and Inequities in Neurological Disease and/or Care in the United States (US)" as it relates to AA and headache medicine.

BACKGROUND

On March 31, 2020 the NINDS issued a RFI "Soliciting Input on Areas of Health Disparities and Inequities in Neurological Disease and/or Care in the US Across the Lifespan", RFI-NOT-NS-20-026, with response date ending June 15, 2020.¹ However as of June 13, 2020, a PubMed search with key terms "African American Headache disparities" yielded few results.

METHODS

Multi-database search and literature review.

RESULTS/DISCUSSION

As of June 13, 2020, a PubMed search with key terms "African American (or Black) Headache disparities" yielded 13 results. Searches of "Migraine Disparities Race" and "Migraine disparities African American" both yielded three results with one non-specific for migraine. In, "Headache disparities race" yielded one result in the PsycINFO database and 23 results in Web of Science database. Key areas of adult headache disparity and/or inequity were health care services for migraine treatment are less utilized, follow-up appointments are terminated more regularly, inaccurate diagnoses are more common, acute migraine attack medications are prescribed less frequently, mistrust and lower quality communication with physicians is reported, mistrust, increased migraine burden, frequency, and severity and risk for progression more associated depression and lower quality of life in AAs compared to non-Hispanic Whites. Literature on race-based disparities is even more scarce in pediatric populations, however it has been shown that white children are significantly more likely to receive neuroimaging than others which may indicate biases in pediatric populations. Potential determinants of these race-based disparities, research strategies and approaches vary and are discussed.

CONCLUSIONS

Race-based disparities exist in headache medicine in the US. Research is needed. Research strategies and approaches currently with limited use in neurology and headache medicine may be warranted and appropriate to address race-based headache disparities. Funding is paramount.

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.

Ondansetron for Acute Migraine in the Pediatric Emergency Department

BACKGROUND

Migraine patients are commonly encountered in the pediatric emergency departments. Much of the research on migraine treatment regimens involves antidopaminergic antiemetics such as prochlorperazine and metoclopramide. Despite a comparably more favorable side effect profile, no migraine treatment research has included ondansetron, a selective type three 5-hydroxytryptamine receptor antagonist. Our primary objective was to determine if treatment regimens including ondansetron were successful in reducing verbal pain scores.

METHODS

We retrospectively reviewed patients with migraine aged seven to 18 years who visited the pediatric emergency departments over a four-year period. Charts were reviewed for initial and discharge pain scores, pediatric emergency department revisits, neurology consultation, and opioid administration. The primary outcome was treatment success, defined as reduction in the verbal pain score of 50% or more. Secondary outcomes included adverse effects, receiving non-evidence-based treatment defined as receiving an opioid, neurology consultation rate, and pediatric emergency department revisit rate within 48 hours.

RESULTS

Ninety-eight encounters were included: 42 received ondansetron, 22 received an antidopaminergic, and 34 received no antiemetic. Thirty-eight patients (90%) in the ondansetron group (95% confidence interval 81 to 99) reached treatment success. Pediatric emergency department revisits, opioid administration, neurology consultation, and treatment success were similar among the ondansetron and antidopaminergic groups.

CONCLUSION

Ondansetron may be a useful medication in the treatment regimen of migraine patients in the pediatric emergency department. Preliminary data suggest that ondansetron is comparable to antidopaminergic agents.

A Critical Exploration of Migraine as a Health Disparity: the Imperative of an Equity-Oriented, Intersectional Approach

PURPOSE OF REVIEW

Despite recognition of rising prevalence and significant burden, migraine remains underestimated, underdiagnosed, and undertreated. This is especially true among groups who have been historically, socially, and economically marginalized such as communities of color, women, people experiencing poverty, people with lower levels of education, and people who hold more than one of these marginalized identities. While there is growing public and professional interest in disparities in migraine prevalence, there is a paucity of research focusing on racial/ethnic and socioeconomic disparities, and the social and structural determinants of health and equity that perpetuate these disparities. From a health equity perspective, migraine research and treatment require an examination not only of biological and behavioral factors, but of these identities and underlying, intersecting social and structural determinants of health.

RECENT FINDINGS

Significant disparities in migraine incidence, prevalence, migraine-related pain and disability, access to care, and quality of care persist among marginalized and underserved groups: African Americans, Hispanics, people experiencing poverty, un- or under-employment, the un- and under-insured, people who have been exposed to stressful and traumatic events across the lifespan, and people experiencing multiple, overlapping marginalized identities. These same groups are largely underrepresented in migraine research, despite bearing disproportionate burden. Current approaches to understanding health disparities in migraine largely assume an essentializing approach, i.e., documenting differences between single identity groups-e.g., race or income or education level-rather than considering the mechanisms of disparities: the social and structural determinants of health. While disparities in migraine are becoming more widely acknowledged, we assert that migraine is more aptly understood as a health equity issue, that is, a condition in which many of the health disparities are avoidable. It is important in research and clinical practice to consider perspectives that incorporate a cultural understanding of racial, ethnic, and socioeconomic identity within and across all levels of society. Incorporating perspectives of intersectionality provides a strong foundation for understanding the role of these complex combination of factors on migraine pain and treatment. We urge the adoption of intersectional and systems perspectives in research, clinical practice, and policy to examine (1) interplay of race, gender, and social location as key factors in understanding, diagnosing, and treating migraine, and (2) the complex configurations of social and structural determinants of health that interact to produce health inequities in migraine care. An intentional research and clinical focus on these factors stands to improve how migraine is identified, documented, and treated among marginalized populations.

Do racial/ethnic disparities exist in recommended migraine treatments in US ambulatory care?

Background Racial disparities in migraine have been reported in the US. Migraine in African Americans (AA) is more frequent, more severe, more likely to become chronic and associated with more depression and lower quality of life compared to non-Hispanic Whites (NHW). It is possible that racial differences in prescribing practices contribute to these differences, but little is known about the quality of migraine prescribing patterns in the US or whether racial differences exist. Objective To determine if racial differences in quality of migraine medical prescription care exist. Methods We used data from the National Ambulatory Medical Care Survey to estimate differences in the use of migraine prophylactic and abortive medications by race. Quality of migraine care was defined using the American Academy of Neurology Headache Quality Measure Set (AAN-HQMS). Patients were assigned to one of four categories representing the overall quality of evidence for their abortive and prophylactic medications using the AAN-HQMS. We hypothesized that there would be suboptimal migraine treatment in minority populations. Racial comparisons were made using descriptive statistics after applying NAMCS survey weights. Results Two thousand, eight hundred and sixty visits were included in the study, representing approximately 50 million migraine visits in the US from 2006-2013. In all, 41.3% of AA, 40.8% of NHW, and 41.2% of Hispanic (HI) patients received no prophylactic treatments ( p = 0.99). A total of 18.8% of AA patients, 11.9% of NHW patients, and 6.9% of HI patients received exclusively Level A prophylaxis ( p = 0.30). A total of 47.1% of AA patients, 38.2% of NHW patients, and 36.3% of HI patients received no abortive treatments ( p = 0.23). In total, 15.3% of AA patients, 19.4% of NHW patients, and 17.7% of HI patients received any Level A abortives (i.e. triptans or Dihydroergotamine; DHE, p = 0.64). A total of 15.2% of all patients had a prescription for opiates, but there were no racial differences. Conclusions Migraine may be undertreated with prophylactic medications. Level A acute analgesics may be underused and opiates overused. No major racial/ethnic differences in abortive or prophylactic treatment were identified.

Headache in African Americans: An Overlooked Disparity

PURPOSE

The persistence of health disparities in the U.S. has necessitated additional research on race-related health disparities among Americans. Remarkably little research has examined race differences in persons with headache disorders, even though 45 million Americans experience episodic or chronic headaches annually. This review paper examined peer-reviewed publication to examine potential race differences in persons with headache disorders in the areas of headache epidemiology, headache characteristics, psychiatric comorbidity, treatment utilization, and treatment outcomes.

PROCEDURES

A multi-database search (PubMed, Web of Science, PsychlNFO) identified U.S. studies that enrolled racially diverse samples of persons with headache disorders and qualitatively examined potential race-related disparities.

MAIN FINDINGS

Compared to their Caucasian counterparts, African American headache patients are more likely to (i) be diagnosed with comorbid depressive disorders; (ii) report headaches that are more frequent and severe in nature, (iii) have their headaches under-diagnosed and/or undertreated; and (iv) discontinue treatment prematurely, regardless of socioeconomic status.

PRINCIPAL CONCLUSIONS

State of the science treatments for chronic headaches are efficacious; unfortunately, race-related disparities prevent African American headache patients from benefiting from these treatments. Research is needed that enables African Americans with severe headaches to access current headache treatments to alleviate headache burden on the African American community.

Preventive medication adherence in African American and Caucasian headache patients

STUDY OBJECTIVES

To examine race-related differences in adherence to preventive medication agents in headache patients and identify factors predictive of medication adherence in Caucasian and African American headache patients.

METHODS

Using a longitudinal naturalistic study design, data from 77 Caucasian and 32 African American headache patients were collected through (1) 30-day daily diaries that assessed medication adherence, headache frequency, and headache episode severity; (2) self-administered surveys that assessed headache management self-efficacy; and (3) telephone-administered psychiatric interviews that yielded psychiatric diagnoses. Using daily diary adherence data, patients' adherence to preventive agents was dichotomized as "Inconsistent" (ie, adhered fewer than 80% of days) or "Consistent" (ie, adhered ≥ 80% of days during the past month).

RESULTS

The proportion of adherent African American patients (69%) did not differ significantly from the proportion of adherent Caucasian patients (82%). Exploratory univariate logistic regression analyses found that preventive medication adherence levels of 80% or less were associated with being diagnosed with major depressive disorder and lower levels of headache management self-efficacy.

CONCLUSIONS

Future research should test if interventions that reduce depressive symptoms and increase patients' levels of headache management self-efficacy can produce concomitant increases in adherence to preventive headache agents.

Race, psychiatric comorbidity, and headache characteristics in patients in headache subspecialty treatment clinics

OBJECTIVE

This research examined how race, psychiatric comorbidity, and headache characteristics are inter-related in patients with severe headache disorders.

DESIGN

This study used a naturalistic cohort design and assessed 114 Black and 173 White patients receiving treatment in headache subspecialty clinics in Cincinnati, Cleveland, Columbus, and Toledo, OH. Face-to-face interviews yielded headache and psychiatric diagnoses; 30-day daily diaries collected data on headache frequency, severity, and disability; and self-administered surveys obtained data on headache management self-efficacy, headache locus of control, and quality of life.

RESULTS

Compared with Whites, Blacks reported more frequent and severe headaches, were more likely to be diagnosed with depressive disorders, and were more likely to be diagnosed with chronic headaches. White and Black patients diagnosed with both depression and anxiety reported the most frequent headache days per month and the lowest levels of life quality and headache management self-efficacy.

CONCLUSIONS

Additional research on race, psychiatric comorbidity, and headache characteristics is needed that can inform culturally contextualized interventions for persons with severe headache disorders.

Triggers, symptoms, and treatment in two populations of migraneurs in Brazil and Spain. A cross-cultural study

BACKGROUND AND AIM

Cultural variation in pain and headache presentation may exist. The objective of this study was to assess cross-cultural differences in the use of drugs commonly managed to treat and prevent migraine, and to analyze the awareness about symptoms and triggers between two populations of migraneurs in Brazil and Spain.

METHODS

International cross-cultural study. Patients answered a socio-demographic questionnaire that included questions about trigger factors, and use of drugs to treat and prevent migraine attacks.

RESULTS

292 patients (mean age 34.6 years; 80% females) were included in the study. Most common identified triggers in Brazilian and Spanish patients were: food (30.5% vs 12.6%), sleep (56.7% vs 28.5%), odors (52.5% vs 9.3%), stress (73.1% vs 46.4%), and menstrual period (55.6% vs 38.1%), all p<0.01. Analgesics and anti-inflammatory drugs were the most commonly used drugs to treat migraine attacks. Brazilian migraneurs used less commonly triptans (16.3% vs 47%; p<0.0001). Prophylactic drugs were used less frequently in Brazil than in Spain (21.9% vs 52.9%; p<0.0001). Calcium-antagonists, tricyclic anti-depressives, beta-blockers, and anti-epileptic drugs were significantly more used in Spanish migraineurs (p<0.01).

CONCLUSIONS

Brazilians migraneurs are more often undertreated for migraine, and underutilization of triptans and preventatives was observed.

Psychosocial headache measures in Caucasian and African American headache patients: Psychometric attributes and measurement invariance

Introduction: As research increasingly examines differences in headache characteristics between Caucasian and African American headache patients, it is requisite to determine the equivalence of existing headache measures for both racial groups.

Methods: This study examined the psychometric properties and measurement invariance of four widely used psychosocial headache measures. Caucasians ( N = 173) and African Americans ( N = 114) receiving treatment in four headache subspecialty clinics throughout Ohio completed the Headache Disability Inventory (HDI), the Migraine-Specific Quality of Life (MSQL) measure, the Headache Management Self-Efficacy (HMSE) scale, and the Headache-Specific Locus of Control (HSLC) scale prior to initiating new preventive therapies.

Conclusion: All measures demonstrated good internal consistency and measurement invariance. Despite adequate measurement invariance, the recommended factor structure of the HMSE scale yielded a poor fit for both African American and Caucasian patients. With perhaps the exception of the HMSE scale, the HDI, MSQL scale and HSLC scale are psychometrically sound and can be used with both Caucasian and African American headache patients.