COMMENTARY

Healthcare Disparities in Migraine Put 'Undue' Disease Burden on Patients

Hope L. O'Brien, MD, MBA; Larry Charleston, IV, MD, MSc

Disclosures

November 19, 2021

Editorial Collaboration

Medscape &

This transcript has been edited for clarity.

Hope L. O'Brien, MD, MBA: Welcome, and thank you for joining us for this discussion on the impact of healthcare disparities on migraine. My name is Hope O'Brien and I'm a neurologist who specializes in headache medicine. I'm also adjunct professor at the University of Cincinnati College of Medicine and medical director at Headache Center of Hope, located in Cincinnati, Ohio. I'm here with my friend and colleague, Dr Charleston, to whom I'll turn this over to make his introduction.

Larry Charleston IV, MD, MSc: I am Larry Charleston IV. I am director of the Headache and Facial Pain Division, director of faculty development, and professor of neurology at Michigan State University, College of Human Medicine, Department of Neurology and Ophthalmology. I'm also adjunct faculty at Jefferson Headache Center.

O'Brien: Dr Charleston, to get us started, can you define what is meant when discussing disparities in healthcare?

Charleston: Yes. There are different definitions. One that I'll use here is from the CDC. Health disparities are defined as "preventable differences in the burden of disease, injury, violence, or in opportunities to achieve optimal health experienced by socially disadvantaged racial, ethnic, and other population groups, and communities."

It's also important to understand and have a basic foundation of a couple of terms. One is equality vs equity. Equality is the concept that "each individual or group of people is given the same resources or opportunities." Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically. Equity recognizes that each person has different circumstances and allocates the exact resources and opportunities needed to reach an equal outcome. Health equity is when everyone has the opportunity to be as healthy as possible.

O'Brien: You've published in the area; however, the COVID-19 pandemic has brought attention to the public that disparities exist in healthcare. In fact, last year, the National Institute of Neurological Disorders and Stroke issued a request for information on areas where disparities and inequities existed in patients with neurological disease. You investigated this request in headache medicine. What are the ways that disparities or inequities exist in migraine?

Charleston: Dr O'Brien, you're absolutely right. Disparities in equity have been an increasing issue of concern in medicine, public health, and health policy over the past four decades. However, inequity in healthcare, medical treatment, and research unfortunately spans much further and much longer than that. Actually, the late, great Dr Martin Luther King Jr declared that "of all forms of inequality, injustice in healthcare is the most shocking and inhumane."

If we fast-forward to the Healthy People 2030 initiative, it presents a goal to eliminate health disparities, achieve health equity, and attain health literacy to improve the health and well-being of all. Migraine is the second most disabling neurological condition in the world. Health disparities are those differences in the prevalence and severity of disease and/or treatments that are rooted in social inequalities and link with social, economic, and/or environmental disadvantages.

Disparities in migraine (such as inaccurate diagnoses) put undue disease burden not only on the people with migraine that are facing migraine care inequity, but also their families, communities, and our society. This impact is social, emotional, economical, and physical. Moreover, we have a duty as healthcare professionals to operate for the good of our patients, and addressing disparities is an ethical principle of justice.

It is true what you said. I may have been one of the first to act on the specific National Institute of Neurological Disorders and Stroke request for information in the area of headache medicine, but thankfully, I was not the only one. There are challenges and concerns that others have taken responsibility to address as well, and we need even more check-ins and advocates in this area.

There are healthcare disparities, when treating headache disorders, that my colleagues and I have broken down in several different areas, such as race or racism. Although races are not inherent biological categories, race is a social construct that acts as a vehicle for systemic racism, and it has a profound health impact.

There's also socioeconomic and health insurance status. Low socioeconomic status is an independent predictor of worse health outcomes, and migraine prevalence is strongly associated with annual household income. Geographic disparities also present a challenge to appropriate access (eg, rural vs urban living) There can be others, whether it's sex, age, religion, etc.

O'Brien: There are many barriers to promoting equity, one of which is access to care or a provider. Many people have no idea what a neurologist does or who we are as a specialty. What are some of the other barriers to addressing healthcare disparities for patients with migraine?

Charleston: That's a great question, Dr O'Brien. First, we would be remiss if we didn't share that there are barriers to migraine care overall. Dr Richard Lipton and colleagues and the late Dr Fred Sheftell and colleagues have explored these barriers over several years. Barriers and challenges to optimal care for people with migraine and other headache disorders exist and result in increased disease burden and impact.

Barriers to effective migraine management include failure to receive an accurate diagnosis, lack of health insurance, lack of appropriate medical consultation, male sex, not being offered a minimal pharmacological treatment regimen, and lack of appropriate education for healthcare providers. Then there may be barriers such as appropriate headache consultation and appropriate acute and preventive pharmacological treatment for migraine, medication overuse, and accurate diagnosis that may exist in patients with chronic vs episodic migraine.

Due to the impact of social determinants of health, we may see an increase in barriers experienced by those patient populations that have been historically marginalized. Discrimination and systemic racism have a long history of influencing the impact of social determinants of health in the US, and I'm learning that this is similar in other countries as well.

Both Black and Latinx patients are less likely to see an outpatient neurologist for neurological disorders (30% vs 40%, respectively), including headache. My colleagues and I observed that African American patient visits accounted for only 10% of all the National Ambulatory Medical Care Survey visits, which is less than what we expect, given the prevalence of the disorder (1 in 6 Americans) and the population of African Americans in the US (12.4%), when we evaluated for patterns of migraine treatment in US ambulatory care.

O'Brien: For those of you who may not know the history of how inequities have come into existence in the US, there have been policies and practices that have favored one population over another. For example, the medical school I graduated from (University of Cincinnati) had the first African American to graduate in 1933. She was a woman by the name of Lucy Oxley, and she was admitted after the institution received pressure from her father's friends, who had a lot of influence in the city.

It wasn't until the 1970s when more conscious efforts were made to diversify medical schools across the country. States went as far as threatening to take away tax exemptions as schools failed to allow entry for Black people.

One of the things I've experienced is that patients are surprised to see a doctor, let alone a neurologist, that looks like me. Black patients will tell me how happy they are to find a doctor that can empathize with their experience as a Black woman. Black, Latinx, and American Indian and Alaska Natives are underrepresented in medicine. We understand the importance of improving the pipeline of diverse providers, but this takes time to educate a new generation of diverse physicians.

Dr Charleston, in what specific ways can we implement change to facilitate better representation and promote equity for patients?

Charleston: In addition to recognizing disparities — we have to recognize the disparities and recognize the inequities — we have to understand our own biases.

I know we are running short of time, but allow me to share a short story. There's an African American young girl who was so excited for school. She was just beginning kindergarten and had been going to class for about 2 weeks. She loved meeting new friends and playing with people. One day, she came home more confused than anything else. She told her mother that when she was trying to play and talk with a potential new friend in her class at recess, this other little girl stated that her dad told her that people with black skin are mean. This young girl is the only African American in her class. This concerned her mother, so her mother told her husband. That husband is me.

Unconscious implicit or conscious explicit biases exist in medicine as well, and we can see that these are systemically taught and can be passed down from generation to generation. We have to start by recognizing our own biases and working with those so that we can better improve the lives of all patients.

O'Brien: Dr Charleston, this was a great conversation to be had. I thank you for your time.

Charleston: Thank you so much, Dr O'Brien.

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