A Review of Underserved and Vulnerable Populations in Headache Medicine in the United States: Challenges and Opportunities.

PURPOSE OF REVIEW: This review will briefly summarize recent literature published on headache disparities in underserved and vulnerable populations. It will also report the personal observations of headache medicine providers working with underserved and vulnerable populations in the USA, specifically in an urban practice dedicated to patients in a safety net program and a rural practice dedicated to Native American patients. RECENT FINDINGS: Headache disorders are recognized as one of the most prevalent neurological conditions. People with headache and migraine encounter several barriers to obtaining appropriate care, which are magnified in vulnerable and underserved populations. Research has shown disparities in headache and migraine diagnosis, prevalence rates, treatment, and outcomes based on race, socioeconomic status, and geography. Continued research regarding disparities in headache medicine is required. Strategies to address the identified challenges, including structural competence and the underrepresented in medicine pipeline, are reviewed.

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.

Primary angiitis of the central nervous system presenting as unilateral optic neuritis.

A middle-aged woman who experienced recurrent episodes of unilateral vision loss and eye pain. On presentation, magnetic resonance imaging (MRI) demonstrated left optic nerve enhancement with patchy hyperintensities in the white matter of both frontal lobes and ill-defined enhancement in a lenticulostriate distribution. Ophthalmologic examination revealed left optic disc edema with a macular scar consistent with neuroretinitis. Her subsequent clinical course was notable for 2 episodes of painful vision loss, without associated neurologic symptoms, which resolved with intravenous and oral steroids. More than 1 year after her initial presentation, the patient developed right facial weakness and slurred speech, and shortly thereafter suffered a fatal intracerebral hemorrhage. Histopathology on autopsy confirmed a diagnosis of primary angiitis of the central nervous system (PACNS). This is an unusual case of PACNS presenting with recurrent unilateral optic neuritis. The vascular enhancement pattern on MRI suggesting inflamed cerebral blood vessels is a rarely described pattern, which likely reflects intracerebral extension of the ocular pathology. The combination of neuroretinitis and perivascular MRI enhancement pattern may represent a subtype of PACNS.

For us by us: Instituting mentorship models that credit minoritized medical faculty expertise and lived experience.

The woefully low proportion of scientists and clinicians underrepresented in medicine (UIM), including members of African-American/Black, Hispanic/Latinx, American Indian/Alaska Native or Native Hawaiian/Pacific Islander communities, is well characterized and documented. Diversity in medicine is not only just, but it improves quality and outcomes. Yet, diversity in academic medicine remains stagnant, despite national recognition and urgent calls to improve diversity, equity, and inclusion across health sciences. One strategy that has shown to improve diversity in many sectors is high quality mentoring. While many institutions have adopted mentoring programs, there remains a lack of mentorship that is equitable, individualized, and sets a clear timeline for academic milestones that will position UIM mentees at the optimal trajectory for promotion and retention. A barrier to assembling these programs is the small number of UIM among the senior faculty ranks who are able to serve in this role, given the disproportionate burden to serve on a multitude of academic committees, task forces, and workgroups to fulfill institutional mandates to diversify representation. These time-consuming services, documented in the literature as the "minority tax," are generally uncompensated and unaccounted for in terms of consideration for promotion, leadership positions, and other measures of career advancement. The Justice, Equity, Diversity, and Inclusion Academic Mentors (JAM) Council represents a novel, culturally responsive, and anti-racist approach to achieve a more equitable and inclusive institutional environment. This approach strategically leverages the intergenerational wisdom and experience of senior UIM faculty via time-protected effort with the overall goals of improving rates of promotion, retention, and career satisfaction of early career UIM colleagues. This community case study describes the rationale, resources needed, processes, and proposed workflow required to launch the JAM Council, as well as the major roles and responsibilities for JAM mentors and mentees, which may be considered by academic medical centers focused on improving diversity among the faculty ranks.

Developing the Neurology Diversity Officer: A Roadmap for Academic Neurology Departments.

Academic Neurology Departments must confront the challenges of developing a diverse workforce, reducing inequity and discrimination within academia, and providing neurologic care for an increasingly diverse society. A neurology diversity officer should have a specific role and associated title within a neurology department as well as a mandate to focus their efforts on issues of equity, diversity and inclusion that affect staff, trainees and faculty. This role is expansive and works across departmental missions but it has many challenges related to structural intolerance and cultural gaps. In this review, we describe the many challenges that diversity officers face and how they might confront them. We delineate the role and duties of the neurology diversity officer and provide a guide to departmental leaders on how to assess qualifications and evaluate progress. Finally, we describe the elements necessary for success. A neurology diversity officer should have the financial, administrative and emotional support of leadership in order for them to carry out their mission and to truly have a positive influence.

Patients' and caregivers' experiences of the impact of Parkinson's disease on health status.

BACKGROUND: Parkinson's disease (PD) is a neurodegenerative disease that significantly affects patients' quality of life. The myriad complexities of the disease, including its nonmotor manifestations, are beginning to be more fully appreciated, particularly in regard to the emotional and social effects of PD. Considering that both motor and nonmotor manifestations of PD significantly influence the health outcomes and conditions of patients, and their health-related quality of life (HRQOL), we collected qualitative data from patients with PD, as well as caregivers of persons with PD having cognitive impairment, to assess their perceptions of the impact of PD on HRQOL. METHODS: We conducted eight focus groups and five one-on-one interviews in English and in Spanish between March 2007 and February 2008. Three of the focus groups were conducted with a total of 15 caregivers; the remaining focus groups and all interviews were conducted with 48 PD patients. Study participants were asked about the challenges that PD patients may experience, particularly pertaining to physical functioning, the impact of PD on their emotional status, and social functioning. RESULTS: Based on analysis of the transcripts, we identified seven overarching domains or themes that reflect patients' perspectives on living with PD, ie, physical functioning, social and role functioning, emotional impact, fears and uncertainty about the future, stigma and other feelings about PD, coping mechanisms, and benefits of having PD. CONCLUSION: We underscore the salient aspects regarding the physical effects of PD along with its nonphysical ramifications, offering perspectives into the experience of PD and suggestions on how PD patients and their caregivers may cope with the disease.

Memantine for prevention of migraine: a retrospective study of 60 cases.

The objective was to retrospectively characterise the efficacy of memantine as preventive therapy in a series of patients with frequent migraine. Patients in a university headache clinic completed a survey regarding their experience with memantine, and medical records were reviewed. All patients who received memantine as preventive therapy for migraine over a 15-month period were mailed surveys and consent forms for record review. Patients were treated with memantine beginning at a dose of 5 mg/day, increasing if needed by 5 mg/week up to 10 mg twice a day. The majority of patients (36 out of 54) treated with memantine for at least 2 months reported a significant reduction in estimated headache frequency, and improved function. Side effects were uncommon and generally mild. This limited retrospective case review suggests that memantine may be an effective preventive therapy for patients with frequent migraine. A prospective trial is warranted.