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ObjectiveTo review the contemporary issues of healthcare disparities in Headache Medicine with regard to race/ethnicity, socioeconomic status and geography and propose solutions for addressing these disparities.MethodsAn 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 this group of 16 experts from a range of headache subspecialties.ResultsTaken together, a multitude of factors including racism, socioeconomic status and insurance status and geographical disparities contribute to the inequities that exist within the healthcare 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.ConclusionNeurologists 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.

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Headache is a leading reason for medical consultation and yet remains underdiagnosed. 1 Headache diseases are highly prevalent and disabling. Migraine alone affects 1 billion people and is the second leading cause of disability worldwide. 2 There still remains a dearth of information surrounding how the headache diseases affect underserved populations and most importantly how this can be addressed. Migraine prevalence studies based in the United States indicate that the prevalence is highest in Native Americans, followed by White Americans, Black Americans, Hispanics, and Asian-Americans. 3,4 Black Americans are less likely to be diagnosed with migraine, in part because they are less likely to endorse full criteria for migraine, and are also less likely to access the medical system for treatment. 3,5 Black men receive the least care for headache diseases nationwide and are less likely to present for ambulatory care for migraine compared with Whites. 6,7 Black patients are less likely to be given pain medications than White patients despite similar self-reports of pain. 8-10 To our knowledge, there are no examples of headache researchers addressing the challenges to inclusion of diverse populations in headache clinical trials. The authors are aware of only three research studies published that specifically examined for racial health disparities in headache medicine. [11][12][13] These studies could be classified as first-generation health disparity research. 14,15

ObjectiveTo review our inpatient experience treating a variety of headache disorders with heterogeneous therapies and to determine outcomes and predictors of response.MethodsWe conducted an IRB-approved retrospective chart review of elective inpatient headache admissions from the Montefiore Headache Center from 2014-2018. We examined factors associated with response and outcomes at discharge and post-hospitalization follow-up in an intractable population. Patients received different classes of intravenous medications including anti-emetics, neuroleptics, dihydroergotamine, lidocaine, steroids, valproic acid (VPA) and nerve blocks, and home preventive medications were either continued or changed before discharge. Improvements were defined at discharge by headache intensity compared to prior to hospitalization.ResultsAmong the 83 admissions, pain improvement at discharge occurred in 90.4% (n=75) of the overall sample, 89.5% (n=60) of those with chronic migraine, 75.0% (n=9) of patients with NDPH, and 89.5% (n=34) of all those with acute medication overuse. Fifty-six patients (67.5%) reported improvement of a 3 or more point reduction in headache intensity at discharge, with a mean reduction of 4.84 +/- SD 2.51 (range 1-10). Of the 66 patients who received IV DHE, 59 (89.4%) of them improved at discharge. Of the 11 (13.2%) patients who received IV lidocaine, 7 (63.6%) improved. Of the 14 (16.9%) patients who received nerve blocks, all 14 (100%) improved at discharge. Of the 75 patients who had improved at discharge, 63 (84%) followed-up and 50 (79.4%) of those patients remained improved. At second follow-up, 68 (81.9%) patients returned for follow-up on average of 71 days (range 10-283) post-discharge.ConclusionOur inpatient headache experience featured numerous treatments with high rates of improvement in the short and intermediate term for all headache disorders. These results may suggest that stratified hospitalized care including polytherapy may be useful for many patients.

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