Migraine care among different ethnicities: do disparities exist?

Association of Race and Ethnicity With Emergency Room Rate of Migraine Diagnosis, Testing, and Management in Children With Headache

BACKGROUND AND OBJECTIVES

Headache evaluation and treatment are believed to be influenced by race and ethnicity. Specific headache diagnosis assigned in the pediatric emergency department (ED) may compound disparities. We sought to investigate racial and ethnic disparities in the diagnosis, testing, and treatment of pediatric patients with headache presenting to the ED.

METHODS

We performed a cross-sectional analysis of ED visits from 49 children's hospitals between 2016 and 2022 from the Pediatric Health Information System, an administrative database of ED and hospitalized encounters within children's hospitals in the United States. Index encounters in the ED from patients (aged 5-21 years, median age 13 [10-15]) with a primary diagnosis of migraine, headache, new daily persistent headache, or tension-type headache were included. Encounters with trauma, infection, and malignancy where secondary headache was possible were excluded. The primary outcomes were the rates of migraine diagnosis, testing, and treatment. We used generalized estimating equations to estimate associations between race and ethnicity and outcomes after adjusting for demographic factors, medical complexity, visit timing, and final headache diagnosis.

RESULTS

A total of 309,678 encounters were included while 61,677 repeat visits, 81,821 visits with diagnoses suggestive of secondary headache, and 5,714 visits from 3 hospitals with sparse data on patient race/ethnicity were excluded. Of 160,466 eligible visits (59.8% female), 41% were by non-Hispanic White (NHW) children, 24.8% non-Hispanic Black (NHB), and 26.0% Hispanic/Latino (HL). NHW children were more frequently diagnosed with migraine (45.5% vs NHB 28.2% and HL 28.3%, p < 0.001). NHB and HL children compared with NHW children received less testing including brain MRI scans (adjusted odds ratio [aOR]: NHB 0.56 [95% CI 0.46-0.69] and HL 0.54 [0.36-0.82]). There was no difference in the proportion of visits without administration of headache-related medications (NHW 23.3% vs NHB 24.6% and HL 23.4%, p = 0.64). NHB and HL children were more likely to receive only oral medications (aOR: NHB 1.37 [1.2-1.56] and HL 1.54 [1.34-1.76]) and less likely to be admitted inpatient (aOR: NHB 0.8 [0.66-0.97] and HL 0.65 [0.44-0.94]).

DISCUSSION

NHB and HL children in the pediatric ED with headache receive fewer migraine diagnoses, less testing, and less intensive treatment compared with NHW children. Beyond affecting headache management, this inequity in migraine diagnosis requires further consideration to include children from marginalized racial and ethnic groups in future migraine research.

The American Headache Society First Contact-Headache in Primary Care program: Current metrics, knowledge assessments, and direction for future initiatives

OBJECTIVE

This study examines the American Headache Society First Contact-Headache in Primary Care program metrics to date in order to assess the program's reach and provide direction for future initiatives.

BACKGROUND

Approximately 4 million primary care office visits annually are headache-specific encounters. Therefore, it is important that primary care providers are knowledgeable about headache management. Recognizing the need, the American Headache Society First Contact designed the comprehensive First Contact-Headache in Primary Care program with input from an advisory board comprised of a diverse group of physicians and advanced practice providers with backgrounds in family and internal medicine, pediatrics, obstetrics and gynecology, and neurology. This is the first study to assess the reach of the program and critically examine how to best meet the needs of clinicians and patients going forward.

METHODS

We report descriptive statistics for the First Contact website metrics from October 2020 to June 2023 and grand rounds program data from May 2020 to December 2023. We also conducted a cross-sectional analysis of survey data from presentations conducted at two large national family medicine symposia, as well as a thematic analysis of the question: "Please indicate what areas of your practice could be enhanced or improved with additional education?"

RESULTS

The First Contact program homepage was the second most visited page on the American Headache Society website (>100,000 views). A total of 20 podcast episodes were created for the program (>3500 plays). The First Contact program held 99 events (72 institutional grand rounds, 22 State-level meetings, and five national meetings), reaching >7000 clinicians. The institutional grand rounds and state-level meetings were held across 27 States and Washington D.C. Only 31.9% (30/94) of First Contact program events (excluding national meetings) occurred in the West census region, which has the fewest headache subspecialists and lowest headache subspecialist density in the United States. When examining survey data of participants who attended the two virtual national family medicine symposia (39.3% response rate, N = 636/1620), 85.7% (544/635) reported being "completely confident" or "very confident" in their ability to recognize and accurately diagnose patients presenting with a primary complaint of headache and 81.5% (517/634) reported being "completely confident" or "very confident" in their ability to develop evidence-based treatment plans that are tailored to the needs of individual patients. The use of diagnostic tools to recognize patients with migraine (60.4%, 384/636) and translating standards of care to the practice setting (42.5%, 270/636) were the most reported intended changes by participants. Most participants reported that program content was of clinical relevance and would improve their patients' outcomes (90.5% [571/631] and 90.6% [572/631], respectively). Over three-quarters (77.8%, 495/636) of participants reported areas of their practice that can be improved by additional education specifically regarding workflow, diagnosis, and management.

CONCLUSION

This study evaluates one of the first national initiatives for primary care education. Data from the two First Contact Family Medicine national symposia indicate the program is generally well received with most participants reporting improved confidence and intention to implement key changes in practice to improve care for patients with headache; however, there remain areas of exploration for education that could further enhance participant experience and expand the reach of the initiatives. Areas for future programming include continued education on multifactorial approaches to headache treatment and suggestions for addressing cost, insurance, and time constraints. Also, future work may examine where the First Contact program might focus initiatives based on specific areas of need in headache care, such as geographic "desert" areas, racial and ethnic disparities, and uninsured/underinsured populations.

Racial Disparities in Time to Huntington Disease Diagnosis in North America: An ENROLL-HD Analysis

Background and Objectives

There are well-documented racial and ethnic disparities in access to neurologic care and disease-specific outcomes. Although contemporary clinical and neurogenetic understanding of Huntington disease (HD) is thanks to a decades-long study of a Venezuelan cohort, there are a limited number of studies that have evaluated racial and ethnic disparities in HD. The goal of this study was to evaluate disparities in time from symptom onset to time of diagnosis of HD.

Methods

Using the ENROLL-HD periodic data set 5 (PDS5), we performed sequential multivariate linear regressions to evaluate sociodemographic factors associated with disparities in time to diagnosis (TTD) for gene-positive individuals (CAG repeats 36+) in the North America region. Sensitivity analyses included imputed multivariate regression analysis of individuals with a total motor score (TMS) of 10 or higher and those with 40+ CAG repeats. We also used descriptive statistics to present TTD data in other ENROLL-HD participating regions.

Results

Among 4717 gene-positive participants in the North American region, 89.5% identified as White, 3.4% as Hispanic or Latino, and 2.3% as African American/Black. The average TTD in the group was 3.78. When adjusting for clinical and sociodemographic variables, Black participants were diagnosed with HD 1 year later than White participants (p < 0.05). Additional factors associated with a later diagnosis included psychiatric symptoms as initial HD symptom, unemployment during baseline ENROLL visit, and higher educational attainment. Sensitivity analysis of gene-positive (36+ CAG) participants with a TMS of 10 or higher and of those with 40+ CAG repeats yielded similar findings.

Discussion

Across multiple statistical models, Black ENROLL-HD participants were diagnosed with HD 1 year later than White participants. Clinical factors suggesting a delay in HD diagnosis included psychiatric symptoms at disease onset and a negative family history of HD. Unemployment during baseline visit and higher educational attainment were sociodemographic factors suggestive of a later diagnosis. Additional multicenter qualitative and quantitative studies are needed to better understand reasons for delays in HD diagnosis among Black individuals, and the role of social and structural determinants of health in obtaining a timely HD diagnosis.

Migraine epidemiology in collegiate student-athletes: Findings from the Concussion Assessment, Research, and Education (CARE) Consortium

OBJECTIVE

This cross-sectional study evaluated de-identified data from the National Collegiate Athletic Association-Department of Defense Grand Alliance from 2014 to 2020 to determine the prevalence of migraine and migraine medication and to describe differences in migraine prevalence by sex, race, and sport.

BACKGROUND

Epidemiological studies can help identify underdiagnosed and undertreated populations. Understanding migraine prevalence in collegiate student-athletes is essential for positive healthcare outcomes including development of prevention and treatment plans.

METHODS

From a concussion baseline assessment, participant's self-reported demographics (e.g., age, sex, sport), migraine diagnosis (i.e., yes/no), and migraine medication usage (e.g., yes/no, type) determined prevalence of migraine and medication use in collegiate student-athletes.

RESULTS

Migraine was reported in 5.6% (2617/47,060; 95% confidence interval [CI] 5.4%-5.8%) of the student-athletes, with higher prevalence in females, 7.5% (1319/17,628; 95% CI 7.1%-7.9%), than males, 4.6% (1298/28,116; 95% CI 4.4%-4.9%). Medication usage was reported by 36.2% (947/2617; 95% CI 34.3%-38.0%) of individuals with migraine. Migraine reporting differed by race, with Caucasian reporting highest (5.9%; 1990/33,913; 95% CI 5.6%-6.1%) and Asian the lowest (2.7%; 55/2027; 95% CI 2.1%-3.5%). Women's sports, including golf, gymnastics, and lacrosse, and men's diving and squash had higher migraine reporting than other sports.

CONCLUSION

Caucasian females reported higher rates than other groups and sport influenced rates of migraine diagnosis.

The headache research priorities: Research goals from the American Headache Society and an international multistakeholder expert group

OBJECTIVE

To identify and disseminate research priorities for the headache field that should be areas of research focus during the next 10 years.

BACKGROUND

Establishing research priorities helps focus and synergize the work of headache investigators, allowing them to reach the most important research goals more efficiently and completely.

METHODS

The Headache Research Priorities organizing and executive committees and working group chairs led a multistakeholder and international group of experts to develop headache research priorities. The research priorities were developed and reviewed by clinicians, scientists, people with headache, representatives from headache organizations, health-care industry representatives, and the public. Priorities were revised and finalized after receiving feedback from members of the research priorities working groups and after a public comment period.

RESULTS

Twenty-five research priorities across eight categories were identified: human models, animal models, pathophysiology, diagnosis and management, treatment, inequities and disparities, research workforce development, and quality of life. The priorities address research models and methods, development and optimization of outcome measures and endpoints, pain and non-pain symptoms of primary and secondary headaches, investigations into mechanisms underlying headache attacks and chronification of headache disorders, treatment optimization, research workforce recruitment, development, expansion, and support, and inequities and disparities in the headache field. The priorities are focused enough that they help to guide headache research and broad enough that they are widely applicable to multiple headache types and various research methods.

CONCLUSIONS

These research priorities serve as guidance for headache investigators when planning their research studies and as benchmarks by which the headache field can measure its progress over time. These priorities will need updating as research goals are met and new priorities arise.

Association between Migraine and Quality of Life, Mental Health, Sleeping Disorders, and Health Care Utilization Among Older African American Adults

PURPOSE

This study examines the associations between migraine headaches, well-being, and health care use among a sample of underserved older African American adults. Controlling for relevant variables, the association between migraine headaches and (1) health care utilization, (2) health-related quality of life (HRQoL), and (3) physical and mental health outcomes was examined.

METHODS

Our sample included 760 older African American adults from South Los Angeles recruited through convenience and snowball sampling. In addition to demographic variables, our survey included validated instruments, such as the SF-12 QoL, Short-Form McGill Pain Questionnaire, and the Geriatric Depression Scale. Data analysis included 12 independent multivariate models using multiple linear regression, log transferred linear regression, binary and multinomial logistic regression, and generalized linear regression with Poisson distribution.

RESULTS

Having migraine was associated with three categories of outcomes: (1) higher level of health care utilization measured by (i) emergency department admissions and (ii) number of medication use; (2) lower level of HRQoL and health status measured by (i) lower self-rated health (ii) physical QoL, and (iii) mental QoL; and (3) worse physical and mental health outcomes measured by (i) higher number of depressive symptoms, (ii) higher level of pain, (iii) sleep disorder, and (iv) being disabled.

CONCLUSIONS

Migraine headache significantly was associated with quality of life, health care utilization, and many health outcomes of underserved African American middle-aged and older adults. Diagnoses and treatments of migraine among underserved older African American adults require multi-faceted and culturally sensitive interventional studies.

Family cascade screening for equitable identification of familial hypercholesterolemia: study protocol for a hybrid effectiveness-implementation type III randomized controlled trial

BACKGROUND

Familial hypercholesterolemia (FH) is a heritable disorder affecting 1.3 million individuals in the USA. Eighty percent of people with FH are undiagnosed, particularly minoritized populations including Black or African American people, Asian or Asian American people, and women across racial groups. Family cascade screening is an evidence-based practice that can increase diagnosis and improve health outcomes but is rarely implemented in routine practice, representing an important care gap. In pilot work, we leveraged best practices from behavioral economics and implementation science-including mixed-methods contextual inquiry with clinicians, patients, and health system constituents-to co-design two patient-facing implementation strategies to address this care gap: (a) an automated health system-mediated strategy and (b) a nonprofit foundation-mediated strategy with contact from a foundation-employed care navigator. This trial will test the comparative effectiveness of these strategies on completion of cascade screening for relatives of individuals with FH, centering equitable reach.

METHODS

We will conduct a hybrid effectiveness-implementation type III randomized controlled trial testing the comparative effectiveness of two strategies for implementing cascade screening with 220 individuals with FH (i.e., probands) per arm identified from a large northeastern health system. The primary implementation outcome is reach, or the proportion of probands with at least one first-degree biological relative (parent, sibling, child) in the USA who is screened for FH through the study. Our secondary implementation outcomes include the number of relatives screened and the number of relatives meeting the American Heart Association criteria for FH. Our secondary clinical effectiveness outcome is post-trial proband cholesterol level. We will also use mixed methods to identify implementation strategy mechanisms for implementation strategy effectiveness while centering equity.

DISCUSSION

We will test two patient-facing implementation strategies harnessing insights from behavioral economics that were developed collaboratively with constituents. This trial will improve our understanding of how to implement evidence-based cascade screening for FH, which implementation strategies work, for whom, and why. Learnings from this trial can be used to equitably scale cascade screening programs for FH nationally and inform cascade screening implementation efforts for other genetic disorders.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT05750667. Registered 15 February 2023-retrospectively registered, https://clinicaltrials.gov/study/NCT05750667 .

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.

Headache in Children and Adolescents

OBJECTIVE

This article reviews the assessment of children and adolescents presenting with headache, provides an overview of primary headache disorders, and reviews evidence-based management of headache in this age group.

LATEST DEVELOPMENTS

In the last few years, new epidemiological data have shed light on less common pediatric headache disorders (eg, pediatric trigeminal autonomic cephalalgias) and psychosocial risk factors associated with primary headache disorders in children and adolescents. There has also recently been a substantial increase in interventions that target the calcitonin gene-related peptide pathway and that treat primary headache disorders using noninvasive neuromodulation. Although these interventions have primarily been studied in adults, there is emerging evidence of their use in the pediatric population.

ESSENTIAL POINTS

Primary headache disorders are very common in youth, and the most commonly encountered headache diagnosis in neurology practice is migraine, which affects approximately 10% of children and adolescents. Diagnosing and effectively treating primary headache disorders before adulthood may have a sustained impact on the patient by improving long-term headache and mental health outcomes, thereby significantly reducing the burden of disability over time. There are several available and emerging acute and preventive interventions for youth with primary headache disorders, and treatment decisions should be made in the context of available evidence using a shared decision-making approach.

Racial and Ethnic Disparities in Neurological Care in the United States

The burden of neurological disease is increasing globally. In the United States, this burden is disproportionally greater for Black and Latino communities who have limited access to neurological care. Health services researchers have attempted to identify racial and ethnic disparities in neurological care and possible solutions. This article reviews the most current literature on racial and ethnic disparities in commonly encountered neurological conditions, including Stroke, Alzheimer's Disease, Multiple Sclerosis, Epilepsy, Parkinson's Disease, and Migraine. Disparities exist in disease incidence, diagnosis, access to care, treatment, outcomes, and representation in epidemiologic studies and clinical trials. Many of the disparities observed in neurological care in the United States are a consequence of longstanding racist and discriminatory policies and legislation that increase risk factors for the development of neurological disease or lead to disparities in accessing quality neurological care. Therefore, additional efforts on the legislative, community health, and healthcare system levels are necessary to prevent the onset of neurological disease and achieve equity in neurological care.

An Analysis of the Role of Mental Health in a Randomized Trial of a Walking Intervention for Black Veterans With Chronic Pain

Black patients and those with co-occurring mental health disorders are disproportionately affected by chronic pain, but few interventions target these populations. This is a secondary analysis of a randomized trial of a walking-focused proactive counseling intervention for Black Veterans with chronic musculoskeletal pain (ACTION). The primary aim was to examine intervention effectiveness among Veterans with an electronic health record-documented mental health diagnosis [depressive disorder, anxiety disorder, substance use disorder, post-traumatic stress disorder or serious mental illness (n = 205)] and those without a diagnosis (n = 175). About 380 Black Veterans receiving care at the Atlanta VA Health Care System were enrolled from 2016 to 2019 and randomized to the intervention or usual care (UC) (1:1). The intervention featured 6 telephone coaching sessions over 8-14 weeks to encourage walking. Participants with a mental health disorder were more likely to complete all counseling sessions (56% vs 38%) and reported improvements in global perceptions of pain and pain intensity/interference (secondary outcomes) at 3-months vs UC. Among participants without a mental health disorder, the intervention was associated with an improvement in pain-related disability at 6-months (primary outcome). Black chronic pain patients with co-occurring mental health disorders may require more intensive treatment to affect improvement in pain-related disability. PERSPECTIVE: This study examines the effectiveness of a walking intervention for chronic pain among Black Veterans with a mental health disorder. These patients were more engaged with the intervention than those without a mental health disorder. However, they did not experience reductions in pain-related disability, suggesting more intensive treatment is needed.

Characteristics and Gender Differences of Headache in the Veterans Health Administration: A National Cohort Study, Fiscal Year 2008-2019

BACKGROUND AND OBJECTIVES

To determine gender differences in headache types diagnosed, sociodemographic characteristics, military campaign and exposures, and health care utilization among US veterans in the Veterans Health Administration (VHA).

METHODS

This study used a retrospective cohort design to examine VHA electronic health record (EHR) data. This cohort includes veterans who had at least 1 visit for any headache between fiscal years 2008 and 2019. Headache diagnoses were classified into 8 categories using International Classification of Disease, Clinical Modification codes. Demographics, military-related exposures, comorbidities, and type of provider(s) consulted were extracted from the EHR and compared by gender. Age-adjusted incidence and prevalence rates of medically diagnosed headache disorders were calculated separately for each type of headache.

RESULTS

Of the 1,524,960 veterans with headache diagnoses included in the cohort, 82.8% were men. Compared with women, men were more often White (70.4% vs 56.7%), older (52.0 ± 16.8 vs 41.9 ± 13.0 years), with higher rates of traumatic brain injury (2.9% vs 1.1%) and post-traumatic stress disorder (23.7% vs 21.7%), and lower rates of military sexual trauma (3.2% vs 33.7%; p < 0.001 for all). Age-adjusted incidence rate of headache of any type was higher among women. Migraine and trigeminal autonomic cephalalgia rates were most stable over time. Men were more likely than women to be diagnosed with headache not otherwise specified (77.4% vs 67.7%) and have higher incidence rates of headaches related to trauma (3.4% vs 1.9% [post-traumatic]; 5.5% vs 5.1% [postwhiplash]; p < 0.001 for all). Men also had fewer headache types diagnosed (mean ± SD; 1.3 ± 0.6 vs 1.5 ± 0.7), had fewer encounters for headache/year (0.8 ± 1.2 vs 1.2 ± 1.6), and fewer visits to headache specialists (20.8% vs 27.4% p < 0.001 for all), compared with women. Emergency department utilization for headache care was high for both genders and higher for women compared with men (20.3% vs 22.9%; p < 0.001).

DISCUSSION

Among veterans with headache diagnoses, important gender differences exist for men and women veterans receiving headache care within VHA regarding sociodemographic characteristics, headache diagnoses, military exposure, and headache health care utilization. The findings have potential implications for providers and the health care system caring for veterans living with headache.

Disparities in the emergency department management of pediatric migraine by race, ethnicity, and language preference

BACKGROUND

There are disparities in pain management for children presenting to the emergency department (ED) according to their racial and ethnic backgrounds. It is not known if there are differences in the treatment of pain associated with pediatric migraines by race, ethnicity, and language for care (REaL).

METHODS

We analyzed treatment patterns and outcomes in our ED for acute migraine in pediatric patients by REaL. Retrospective data on treatments, length of stay (LOS), and charges were collected from the electronic medical record for pediatric patients on the ED migraine pathway from October 2016 to February 2020. Patient race/ethnicity and language for care were self-reported at registration. We analyzed two treatment groups: receipt of oral (PO) or intranasal (IN) medications only or intravenous (IV) ± IN/PO medications. A total of 833 patients (median age 14.8 years, interquartile range [IQR] 12.3-16.5 years; 67% female, 51% non-Hispanic White (nHW), 23% Hispanic, 8.3% Black or African American, 4.3% Asian) were included. A total of 287 received PO/IN medications only and 546 received IV medications.

RESULTS

Initial pain scores in the two groups were similar. Patients who were Asian, Black or African American, and Hispanic or had a language for care other than English (LOE) had significantly lower odds of receiving IV treatment, while patients who were nHW and preferred English had higher odds of receiving IV treatment. The IV treatment group had longer LOS and ED charges. Pediatric ED patients with migraine who were Black, Asian, and Hispanic or had a LOE had a decreased likelihood of receiving IV therapies while patients who were nHW were more likely to receive IV treatments, despite similar initial pain scores.

CONCLUSIONS

These data align with previous studies on pain management disparities and highlight another area where we must improve equity for patients in the ED.

The relationship between patients' income and education and their access to pharmacological chronic pain management: A scoping review

Background

Though chronic pain is widespread, affecting about one-fifth of the world's population, its impacts are disproportionately felt across the population according to socioeconomic determinants such as education and income. These factors also influence patients' access to treatment, including pharmacological pain management.

Aim

A scoping review was undertaken to better understand the association of socioeconomic factors with physicians' pain management prescribing patterns for adults living with chronic pain.

Methods

An electronic literature search was conducted using the EMBASE, CINAHL, SCOPUS, and Ovid MEDLINE databases and 31 retrieved articles deemed relevant for analyses were critically appraised.

Results

The available evidence indicates that patients' lower socioeconomic status is associated with a greater likelihood of being prescribed opioids to manage their chronic pain and a decreased likelihood of receiving prescription medications to manage migraines, rheumatoid arthritis, and osteoarthritis.

Conclusions

These results suggest that individuals with lower socioeconomic status do not receive equal prescription medicine opportunities to manage their chronic pain conditions. This is influenced by a variety of intersecting variables, including access to care, the potential unaffordability of certain therapies, patients' health literacy, and prescribing biases. Future research is needed to identify interventions to improve equity of access to therapies for patients with chronic pain living in lower socioeconomic situations as well as to explain the mechanism through which socioeconomic status affects chronic pain treatment choices by health care providers.

Abbreviation

SES: socioeconomic status; RA: rheumatoid arthritis; IV: intravenous; SC: subcutaneous; bDMARDs: biological disease-modifying antirheumatic drugs; DMARDS; disease-modifying antirheumatic drugs; TNFi: tumour necrosis factor inhibitors; NSAIDs: non-steroidal anti-inflammatory drugs.

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.

Race, ethnicity, and other sociodemographic characteristics of patients with hospital admission for migraine in the United States

BACKGROUND

Despite the growing awareness across the general population, migraine is often underdiagnosed and undertreated in socially and economically marginalized groups. The present study aimed to investigate the differential effects of race and income on other sociodemographic data and hospital length of stay in patients admitted to hospital with a primary diagnosis of migraine headache.

METHODS

We utilized the Nationwide Inpatient Sample (NIS) database to identify patients admitted to the hospital from 2004 to 2017 with primary diagnosis of migraine. Information on demographic and length of stay data was obtained. Only patients older than 18 years were selected and age outliers were excluded. Race groups were identified as "White", "Black", "Asian or Pacific Islander", "Native American", or "Other ethnic group", as originally reported in the NIS database. Income was identified as the estimated median household income of residents in the patient's ZIP Code.

RESULTS

A total of 106,761,737 valid cases were identified. After applying our case inclusion criteria, only 61453 (median age= 42 years, range= 18-78 years) were included. Patients identified as "Black", "Hispanic" or "Native Americans" were more likely to have lower household income (p < 0.001), whereas higher income was found for the patients identified as "White"", even when men and women were considered separately (p < 0.001). No effects of race and/or household income was found on the length of stay in hospital.

IMPLICATIONS

The occurrence of migraine diagnosis on hospital admission in the USA can be impacted by dramatic culturally driven patient-clinician communication differences between ethnic groups.

Phenome-wide analysis highlights putative causal relationships between self-reported migraine and other complex traits

BACKGROUND

Migraine is a complex neurological disorder that is considered the most common disabling brain disorder affecting 14 % of people worldwide. The present study sought to infer potential causal relationships between self-reported migraine and other complex traits, using genetic data and a hypothesis-free approach.

METHODS

We leveraged available summary statistics from genome-wide association studies (GWAS) of 1,504 phenotypes and self-reported migraine and inferred pair-wise causal relationships using the latent causal variable (LCV) method.

RESULTS

We identify 18 potential causal relationships between self-reported migraine and other complex traits. Hypertension and blood clot formations were causally associated with an increased migraine risk, possibly through vasoconstriction and platelet clumping. We observed that sources of abdominal pain and discomfort might influence a higher risk for migraine. Moreover, occupational and environmental factors such as working with paints, thinner or glues, and being exposed to diesel exhaust were causally associated with higher migraine risk. Psychiatric-related phenotypes, including stressful life events, increased migraine risk. In contrast, ever feeling unenthusiastic / disinterested for a whole week, a phenotype related to the psychological well-being of individuals, was a potential outcome of migraine.

CONCLUSIONS

Overall, our results suggest a potential vascular component to migraine, highlighting the role of vasoconstriction and platelet clumping. Stressful life events and occupational variables potentially influence a higher migraine risk. Additionally, a migraine could impact the psychological well-being of individuals. Our findings provide novel testable hypotheses for future studies that may inform the design of new interventions to prevent or reduce migraine risk and recurrence.

Experiences of racial discrimination in the medical setting and associations with medical mistrust and expectations of care among black patients seeking addiction treatment

INTRODUCTION

Experiences of racial discrimination in the medical setting are common among Black patients and may be linked to mistrust in medical recommendations and poorer clinical outcomes. However, little is known about the prevalence of experiences of racial mistreatment by healthcare workers among Black patients seeking addiction treatment, or how these experiences might influence Black patients' medical mistrust or expectations of care.

METHODS

Participants were 143 Black adults recruited consecutively from two university addiction treatment facilities in Columbus, Ohio. All participants completed validated surveys assessing perceptions of prior racial discrimination in the medical setting and group-based medical mistrust. Participants were also asked a series of questions about their expectations of care with regard to racial discrimination and addiction treatment. Descriptive analyses were used to characterize the sample with regard to demographics, perceived racial discrimination and medical mistrust. Kendall tau-b correlations assessed relationships between racial discrimination, mistrust and expectations of care.

RESULTS

Seventy-nine percent (n = 113) of participants reported prior experiences of racial discrimination during healthcare. Racial discrimination in the medical setting was associated with greater mistrust in the medical system and worse expectations regarding racial discrimination in addiction treatment including delays in care-seeking due to concern for discrimination, projected non-adherence and fears of discrimination-precipitated relapse.

CONCLUSIONS

Black patients seeking addiction treatment commonly report experiencing racial discrimination by healthcare workers which may be associated with mistrust in the medical system and expectations of care. Strategies to eliminate and mitigate experiences of racial discrimination may improve addiction treatment receptivity and engagement.

Barriers to care in episodic and chronic migraine: Results from the Chronic Migraine Epidemiology and Outcomes Study

OBJECTIVE

To assess rates of and factors associated with traversing fundamental barriers to good medical outcomes and pharmacologic care in individuals with episodic migraine (EM) and chronic migraine (CM), including socioeconomic status and race.

BACKGROUND

Barriers to good outcomes in migraine include the lack of appropriate medical consultation, failure to receive an accurate diagnosis, not being offered a regimen with acute and preventive pharmacologic treatments (if indicated), and not avoiding medication overuse.

METHODS

The Chronic Migraine Epidemiology and Outcomes (CaMEO) Study was a longitudinal Internet-based survey. Respondents who met criteria for migraine consistent with the International Classification of Headache Disorders, 3rd edition, had a Migraine Disability Assessment score ≥ 6, and provided health insurance coverage status were included in this analysis. Successfully traversing each barrier to care and the effects of sociodemographic characteristics were examined.

RESULTS

Among 16,789 respondents with migraine, 9184 (54.7%; EM: 7930; CM: 1254) were eligible. Current headache consultation was reported by 27.6% (2187/7930) of EM and 40.8% (512/1254) of CM respondents. Among consulters, 75.7% (1655/2187) with EM and 32.8% (168/512) with CM were accurately diagnosed. Among diagnosed consulters, 59.9% (992/1655) with EM and 54.2% (91/168) with CM reported minimally appropriate acute and preventive pharmacologic treatment. Among diagnosed and treated consulters, in the EM group 31.8% (315/992) and in the CM group 74.7% (68/91) met medication overuse criteria. Only 8.5% (677/7930) of EM and 1.8% (23/1254) of CM respondents traversed all four barriers. Higher income was positively associated with likelihood of traversing each barrier. Blacks and/or African Americans had higher rates of consultation than other racial groups. Blacks and/or African Americans and multiracial people had higher rates of acute medication overuse.

CONCLUSIONS

Efforts to improve care should focus on increasing consultation and diagnosis rates, improving the delivery of all appropriate guideline-based treatment, and avoidance of medication overuse.

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.

Racial Differences in Disease Presentation and Management of Intracranial Meningioma

Objective/Hypothesis  The aim of the study was to determine the impact of race on disease presentation and treatment of intracranial meningioma in the United States. Study Design  This study comprised of the analysis of a national population-based tumor registry. Methods  Analysis of the surveillance, epidemiology, and end results (SEER) database was performed, including all patients identified with a diagnosis of intracranial meningioma. Associations between race, disease presentation, treatment strategy, and overall survival were analyzed in a univariate and multivariable model. Results  A total of 65,973 patients with intracranial meningiomas were identified. Of these, 45,251 (68.6%) claimed white, 7,796 (12%) black, 7,154 (11%) Hispanic, 4,902 (7%) Asian, and 870 (1%) patients reported "other-unspecified" or "other-unknown." The median annual incidence of disease was lowest among black (3.43 per 100,000 persons) and highest among white (9.52 per 100,000 persons) populations ( p  < 0.001). Overall, Hispanic patients were diagnosed at the youngest age and white patients were diagnosed at the oldest age (mean of 59 vs. 66 years, respectively; p  < 0.001). Compared with white populations, black, Hispanic, and Asian populations were more likely to present with larger tumors ( p  < 0.001). After controlling for tumor size, age, and treatment center in a multivariable model, Hispanic patients were more likely to undergo surgery than white, black, and Asian populations. Black populations had the poorest disease specific and overall survival rates at 5 years following surgery compared with other groups. Conclusion  Racial differences among patients with intracranial meningioma exist within the United States. Understanding these differences are of vital importance toward identifying potential differences in the biological basis of disease or alternatively inequalities in healthcare delivery or access Further studies are required to determine which factors drive differences in tumor size, age, annual disease incidence, and overall survival between races.

Psychometric Properties of the Psychosocial Assessment Tool-Chronic Pain Version in Families of Children With Headache

Children with headache disorders are at increased psychosocial risk, and no validated screening measures exist to succinctly assess for risk. This study examined the psychometric properties of the Psychosocial Assessment Tool-Chronic Pain, a previously adapted screening measure of risk, in a retrospective sample of families of children diagnosed with headaches. Participants included 127 children and caregivers presenting for behavioral health evaluation of headache. Children and their primary caregivers completed several psychosocial assessment measures. Internal consistency for the Psychosocial Assessment Tool-Chronic Pain total score was high (α = 0.80), and all subscale scores had moderate to high internal consistency (α = 0.597-0.88), with the exception of the caregiver beliefs subscale (α = 0.443). The total score and the majority of subscale scores on the Psychosocial Assessment Tool-Chronic Pain were correlated with caregiver- and child-reported scores on study measures. The results demonstrate that the Psychosocial Assessment Tool-Chronic Pain has adequate psychometric properties, and because of the brief administration time, ease of scoring, and accessibility of the measure, it is a promising measure of screening for psychosocial risk in this population.

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.

Off-Label Prescribing for Children with Migraines in U.S. Ambulatory Care Settings

BACKGROUND

Migraines, Which Affect About 10% Of School-Age Children In The United States, Can Significantly Impair Quality Of Life. Despite Potential Disability, Many Children Do Not Receive Treatment Or Prophylaxis, Since Medications Specifically Approved For Children Are Significantly Less Than For Adults. There Is Also Controversy Surrounding The Apparent Widespread Practice Of Prescribing Off-Label Medications For Children With Migraines. However, Little Research Has Been Done To Identify Physician-Prescribing Patterns Of Migraine Medication For Children.

OBJECTIVE

To Investigate The Prevalence And Pattern Of Off-Label Prescribing For Children With Migraines.

METHODS

A Secondary Data Analysis Was Conducted Using The Pooled National Ambulatory Medical Care Survey (Namcs) 2011 And 2012. Patients Aged 17 Years Or Younger With A Migraine Diagnosis Were Included. A Series Of Weighted Descriptive Analyses Were Used To Estimate The Prevalence Of Migraine Drugs Prescribed During Pediatric Office Visits. A Weighted Logistic Regression Was Constructed To Compare The Prescribing Patterns Between Off-Label And Fda-Approved Medications. Analyses Used Sas 9.4 Methodology And Incorporated Sample Weights To Adjust For The Complex Sampling Design Employed By Namcs.

RESULTS

Of The 12.9 Million Outpatient Visits With A Migraine Diagnosis That Took Place Between 2010 And 2012, 1.2 Million Were Pediatric Visits. Females Accounted For Nearly Twice The Number Of Migraine Visits Than Males (66% Vs. 34%). Children Aged 12-17 Years Accounted For The Highest Frequency Of Visits (84%), Compared With Those Aged Under 12 Years (16%). 66.7% Of These Pediatric Patients Received At Least 1 Migraine Drug. Of These, Off-Label Medications Were Prescribed 1.5 Times More Than Fda-Approved Medications For Children (60.34% Vs. 39.65%). The Results Of Logistic Regression Showed A Significant Likelihood Of Prescribing Off-Label Medications Based On Physician Specialty, Patient Race, And Reason For Visit. Neurologists (Or = 0.028, P < 0.05) And Pediatricians (Or = 0.095, P < 0.05) Were Less Likely To Prescribe Off-Label Drugs Than General And Family Practitioners. Visits For Preventive Care (Or = 5.8, P < 0.05) And Flare-Ups From Chronic Migraines (Or = 5.0, P < 0.05) Were More Likely To Result In Off-Label Drug Prescriptions Than Visits For New Migraine Incidence.

CONCLUSIONS

This Study Provides Significant Real-World Evidence Of The Widespread Practice Of Prescribing Off-Label Drugs To Children With Migraines. Although Medical Literature Shows That Off-Label Prescribing May Not Be Harmful, There Is A Dearth Of Research And Practice Guidelines To Help Practitioners Uphold Safety Standards And Ensure The Prescription Of Age-Appropriate Medications To Children.

DISCLOSURES

No outside funding supported this study. The authors report no potential conflicts of interest relevant to this research. Lai and Ting contributed to study concept and design and collected the data, along with the other authors. Data interpretation was performed by Lai, Koh, Obi, Ho, and Ting. The manuscript was written and revised by Lai, Koh, and Ho, with assistance from Ting and Obi.

A critical review of manual therapy use for headache disorders: prevalence, profiles, motivations, communication and self-reported effectiveness

Background

Despite the expansion of conventional medical treatments for headache, many sufferers of common recurrent headache disorders seek help outside of medical settings. The aim of this paper is to evaluate research studies on the prevalence of patient use of manual therapies for the treatment of headache and the key factors associated with this patient population.

Methods

This critical review of the peer-reviewed literature identified 35 papers reporting findings from new empirical research regarding the prevalence, profiles, motivations, communication and self-reported effectiveness of manual therapy use amongst those with headache disorders.

Results

While available data was limited and studies had considerable methodological limitations, the use of manual therapy appears to be the most common non-medical treatment utilized for the management of common recurrent headaches. The most common reason for choosing this type of treatment was seeking pain relief. While a high percentage of these patients likely continue with concurrent medical care, around half may not be disclosing the use of this treatment to their medical doctor.

Conclusions

There is a need for more rigorous public health and health services research in order to assess the role, safety, utilization and financial costs associated with manual therapy treatment for headache. Primary healthcare providers should be mindful of the use of this highly popular approach to headache management in order to help facilitate safe, effective and coordinated care.

Minority Representation in Migraine Treatment Trials

BACKGROUND

Minorities have historically been underrepresented in clinical research trials despite having comparatively poor health indicators. Recognizing the dual inequalities of increased disease burden and decreased research participation, the National Institute of Health (NIH) Revitalization Act of 1993 mandated the inclusion and reporting of women and minorities in NIH-funded research. While progress has been made in the subsequent decades, this underrepresentation of minorities in research trials persists and has been documented in multiple disciplines. However, the extent of adequate representation and reporting of minority inclusion in clinical trials for migraine remains unknown.

OBJECTIVES

In this systematic review and study, we review the literature examining the representation of women and minorities in migraine clinical research trials METHODS: First we searched PubMed for pertinent articles examining the inclusion of women and minorities in migraine clinical research trials. Second, we identified controlled-trials for migraine published since 2011 in major neurology, headache, and general medicine journals using the terms "migraine randomized controlled trial." We then reviewed the results manually and excluded pilot studies and those with fewer than 50 participants. We next determined (a) how frequently representation of minorities and women were reported in these major trials; (b) what factors correlated with reporting; and (c) whether women and minority inclusion comprised their ratios in the general population.

RESULTS

We identified 128 relevant clinical trials, of which 36 met our inclusion criteria. All 36 trials (100%) reported gender frequency, and 25 of 36 (69.4%) reported ethnicity or race. Among all studies, women and Whites represented 84.2 and 82.9% of participants (mean), respectively. Studies conducted in the United States and funded by a private company were more likely to report race than studies conducted exclusively outside of the U.S. or with a public sponsor. No studies stratified efficacy or safety by ethnicity or gender. Men and non-Whites in the U.S. were statistically underrepresented.

CONCLUSIONS

Most recent headache studies comply with the NIH mandate to include women and minorities in research trials, particularly U.S.-based and industry-funded studies. Whites are overrepresented compared to both the general population and the population of migraineurs. Future studies should strive to increase minority participation and investigate race-based differences in migraine expression, treatment response, and medication toxicity.

Hypertension and Migraine in the Northern Manhattan Study

OBJECTIVE

To investigate the association between migraine and hypertension in the Northern Manhattan Study (NOMAS), a multiethnic community-based sample.

DESIGN

Cross-sectional cohort study.

PARTICIPANTS

1338 NOMAS participants (mean age 68.1 ± 9.6 years, 37% male, 15% non-Hispanic White, 19% non-Hispanic Black, 67% Hispanic).

SETTING

Northern Manhattan community.

INTERVENTION

Participants were assessed for migraine symptoms using a self-report questionnaire based on criteria from the International Classification of Headache Disorders. Hypertension was defined as blood pressure ≥140/90 mm Hg, the patient's self-reported hypertension, or use of anti-hypertensive medications. Duration (≤9 years vs >9 years) and control (BP<140/90) of hypertension were examined. We estimated the association between hypertension and migraine (overall and with/without aura) using logistic regression, adjusting for sociodemographic and vascular risk factors.

RESULTS

The majority of participants (80%) had no migraine, 6% had migraine with aura, and 15% had migraine without aura. Hypertension was present in 76% of the study population (7% had controlled hypertension ≤9 years duration, 5% controlled hypertension >9 years duration, 41% uncontrolled hypertension ≤9 years duration, 23% uncontrolled hypertension >9 years duration). Hypertension was associated with migraine (OR: 1.76, 95% CI: 1.21-2.54), both with and without aura. This association was particularly apparent for those with uncontrolled and long duration hypertension.

CONCLUSION

Hypertension, particularly uncontrolled and of long duration, is associated with migraine, both with and without aura, in a predominantly Hispanic community-based cohort.

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.

Prevalence of migraine in a diverse community--electronic methods for migraine ascertainment in a large integrated health plan

INTRODUCTION

The growing availability of electronic health data provides an opportunity to ascertain diagnosis-specific cases via systematic methods for sample recruitment for clinical research and health services evaluation. We developed and implemented a migraine probability algorithm (MPA) to identify migraine from electronic health records (EHR) in an integrated health plan.

METHODS

We identified all migraine outpatient diagnoses and all migraine-specific prescriptions for a five-year period (April 2008-March 2013) from the Kaiser Permanente, Northern California (KPNC) EHR. We developed and evaluated the MPA in two independent samples, and derived prevalence estimates of medically-ascertained migraine in KPNC by age, sex, and race.

RESULTS

The period prevalence of medically-ascertained migraine among KPNC adults during April 2008-March 2013 was 10.3% (women: 15.5%, men: 4.5%). Estimates peaked with age in women but remained flat for men. Prevalence among Asians was half that of whites.

CONCLUSIONS

We demonstrate the feasibility of an EHR-based algorithm to identify cases of diagnosed migraine and determine that prevalence patterns by our methods yield results comparable to aggregate estimates of treated migraine based on direct interviews in population-based samples. This inexpensive, easily applied EHR-based algorithm provides a new opportunity for monitoring changes in migraine prevalence and identifying potential participants for research studies.

African Americans’ Perceptions of Pain and Pain Management

Purpose: The purpose of this systematic review is to explore the perceptions of acute, persistent, and disease-specific pain and treatment options held by adult African Americans. Underassessment and undermanagement of pain in African Americans has been well documented; however, the cultural continuum of pain perceptions and their influence on pain assessment and management has not been synthesized. Design: Electronic database searches of the Cumulative Index for Nursing and Allied Health Literature and PubMed, Web-based searches of the pain-specific journals plus a manual search of reference lists identified 41 relevant articles addressing perceptions of pain and/or pain management. Findings: Analysis of the literature revealed six themes: (a) meaning of pain, (b) description of pain, (c) coping with pain, (d) impact of pain, (e) patient–provider relationship, and (f) treatment approaches. Conclusion: These findings warrant further research and indicate the need for more precise evaluation of pain in African Americans, highlighting an imperative to incorporate cultural patterns into pain management practice and education.

Identified risk factors and adolescents' beliefs about triggers for headaches: results from a cross-sectional study

Although there are few studies on adolescents' beliefs about triggers of headache, none of these compared the associations between perceived and observed triggers. This study aimed at comparing the prevalence of self-perceived and observed risk factors for headache among adolescents. Adolescents from the 10th and 11th grades of high schools answered questionnaires on their headaches and on potential risk factors regarding lifestyle, stress and muscle pain. Individuals reporting to have experienced headache in the preceding 6 months were asked to report what they believed to cause their headache (self-perceived triggers). 1,047 (83 %) of 1,260 adolescents reported headaches. Stress, lack of sleep and too much school work were the most frequently reported self-perceived triggers of headache; in contrast the statistical analysis identified alcohol and coffee consumption, smoking, neck pain, stress and physical inactivity as risk factors for headache. Among individuals with headache, 48 % believed that stress might trigger their headaches, while increased stress scores were only observed in 23 %. In contrast, while 7, 4, 0.3 and 0 % of individuals reporting headache considered consumption of too much alcohol, neck pain, physical inactivity and consumption of coffee might trigger their headache, 56, 51, 36 and 14 %, respectively, were exposed to these risk factors. The prevalence of self-perceived triggers of headache does not correspond to the prevalence of identified risk factors for headaches. While the role of stress was overestimated, the high prevalence of the other confirmed risk factors in adolescents with headache suggests potential for prevention by increasing awareness for these risk factors and appropriate interventions.

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.

Time to take stock: a meta-analysis and systematic review of analgesic treatment disparities for pain in the United States

BACKGROUND

The recent Institute of Medicine Report assessing the state of pain care in the United States acknowledged the lack of consistent data to describe the nature and magnitude of unrelieved pain and identify subpopulations with disproportionate burdens.

OBJECTIVES

We synthesized 20 years of cumulative evidence on racial/ethnic disparities in analgesic treatment for pain in the United States. Evidence was examined for the 1) magnitude of association between race/ethnicity and analgesic treatment; 2) subgroups at an increased risk; and 3) the effect of moderators (pain type, setting, study quality, and data collection period) on this association.

METHODS

United States studies with at least one explicit aim or analysis comparing analgesic treatment for pain between Whites and a minority group were included (SciVerse Scopus database, 1989-2011).

RESULTS

Blacks/African Americans experienced both a higher number and magnitude of disparities than any other group in the analyses. Opioid treatment disparities were ameliorated for Hispanics/Latinos for "traumatic/surgical" pain (P = 0.293) but remained for "non-traumatic/nonsurgical" pain (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.64-0.77, P = 0.000). For Blacks/African Americans, opioid prescription disparities were present for both types of pain and were starker for "non-traumatic/nonsurgical" pain (OR = 0.66, 95% CI = 0.59-0.75, P = 0.000). In subanalyses, opioid treatment disparities for Blacks/African Americans remained consistent across pain types, settings, study quality, and data collection periods.

CONCLUSION

Our study quantifies the magnitude of analgesic treatment disparities in subgroups of minorities. The size of the difference was sufficiently large to raise not only normative but quality and safety concerns. The treatment gap does not appear to be closing with time or existing policy initiatives. A concerted strategy is needed to reduce pain care disparities within the larger quality of care initiatives.

Expert opinion: what causes migraine: which physician explanation do patients prefer and understand?

BACKGROUND

Although "What causes migraine," is one of the most common questions migraineurs ask their physicians, little is known about what response physicians provide, whether migraineurs believe it is important that they be provided information, or which explanation is most informative.

METHODS

Seven migraine specialists were personally contacted and a convenience sample of 23 neurologists were surveyed at a meeting to obtain a range of explanations. Four explanations were selected and edited. One hundred consecutive patients seen in a general neurology practice participated in the study.

RESULTS

The mean response on a 5-point Likert scale to the statement, "It is important to provide patients an explanation of what causes migraine," of 15 neurologists surveyed at a meeting was 4.3 (5 = strongly agree). One hundred consecutive patients participated in the study with a mean age of 39.1 years and 87 females. The mean response to the question, "How important is it for a physician to provide you with an explanation of what causes migraine?" was 4.7 on a 5-point Likert scale (5 = very important). The explanation preferred by most (56) of the subjects was the longest (245 words) with the fewest (4) choosing the briefest (25 words).

CONCLUSIONS

This study suggests that neurologists and migraineurs believe that it is very important for a physician to provide them with an explanation of what causes migraine. An explanation that may be most informative may contain information in lay terms about the pathophysiology and the many triggers. The physician can provide explanations verbally, through handouts, or by referral to internet sites. Better patient understanding of what causes migraine may improve treatment adherence and patient satisfaction.

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.

Ethnic Group Differences in the Outcomes of Multidisciplinary Pain Treatment

OBJECTIVES: The aim of this prospective investigation was to evaluate ethnic group differences in pain-related outcomes following multidisciplinary chronic pain treatment. A prospective pre- and post-treatment assessment design was employed to investigate the effects of ethnicity on changes in pain-related variables following completion of a multidisciplinary pain treatment program. METHODS: One hundred fifty five chronic pain patients participating in a multidisciplinary pain treatment program completed measures of pain and mood both prior to and following the four-week treatment. Primary outcome variables included pain severity, pain-related interference, and depressive symptoms. RESULTS: Baseline differences between African-Americans and Whites were observed for depressive symptoms, but not for pain severity or pain-related interference. Following multidisciplinary pain treatment, both White and African-American patients displayed post-treatment reductions in depressive symptoms and pain-related interference. However, White patients also reported reduced pain severity while African-Americans did not. CONCLUSIONS: The treatment approach used in the present study appeared to be less effective in reducing self-reported pain severity in African-American versus White patients, though both groups benefited in terms of reduced depressive symptoms and pain-related interference. Moreover, the observation that improvements in functioning occurred without reductions in pain severity in African-American patients suggests that differences may exist in treatment processes as a function of ethnic group, and will consequently be an important area for future research.

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.

Validation of the group-based medical mistrust scale among urban black men

BACKGROUND

Socioculturally relevant measures of medical mistrust are needed to better address health disparities, especially among Black men, a group with lower life expectancy and higher death rates compared to other race/gender groups.

OBJECTIVES

The study aim was to investigate the psychometric properties of the Group-Based Medical Mistrust Scale (GBMMS) in a Black male sample.

DESIGN

Data were collected as part of a randomized controlled trial testing educational strategies to support Black men's decisions about prostate cancer screening.

PARTICIPANTS

Participants included 201 Black men ages 40-75 years recruited in New York City during 2006-2007.

MAIN MEASURES

The primary measures included: race-based medical mistrust, health care participation, avoidance of health care, perceived access to health care, health care satisfaction, racial identity, residential racial segregation, attitudes towards prostate cancer screening, and past prostate cancer screening behavior.

KEY RESULTS

An exploratory factor analysis suggested a three-factor structure. Confirmatory factor analysis supported the three-factor model. Internal consistency was high for the total GBMMS and the three sub-scales: Suspicion, Discrimination, and Lack of Support. Construct validity was supported by: significant positive correlations between GBMMS and avoidance of health care and racial identity as well as significant negative correlations with health care access, health care satisfaction, and attitudes about prostate cancer screening. ANOVA showed that the GBMMS was associated with greater residential racial segregation. Higher total GBMMS scores were associated with not visiting a physician in the last year and not having a regular physician.

CONCLUSIONS

The present findings provide strong additional evidence that the GBMMS is a valid and reliable measure that may be used among urban Black men.