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.

Healthcare disparities encountered by patients with headache disorders and potential mitigation strategies.

This chapter discusses the healthcare disparities in headache medicine and proposes solutions to mitigate them. Disparities exist in the diagnosis, treatment, and outcomes of underserved patients with migraine and other headache disorders. Systemic racism, provider bias and lack of cultural sensitivity, a history of mistrust and historical injustices, lack of research of underrepresented groups, lack of diversity in clinical and research realms as well as leadership positions within national institutions and organizations all contribute to the ongoing disparities in headache medicine. Making strides in increasing the diversity of the clinical and research workforce, training providers on cultural sensitivity, providing mentorship programs to underrepresented groups in headache medicine, increasing funding for headache medicine disparity research, and facilitating participation of underrepresented groups in research are all potential ways to address disparities.

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.

Elective Hospitalizations for Intractable Headache: Outcomes and Response Predictors.

OBJECTIVE: To review our inpatient experience treating a variety of headache disorders with heterogeneous therapies and to determine outcomes and predictors of response. METHODS: We conducted an institutional review board-approved retrospective chart review of elective inpatient headache admissions from the Montefiore Headache Center from 2014 to 2018. We examined factors associated with response and outcomes at discharge and posthospitalization follow-up in an intractable population. Patients received different classes of IV medications including antiemetics, neuroleptics, dihydroergotamine, lidocaine, steroids, valproic acid, and nerve blocks, and home preventive medications were either continued or changed before discharge. Improvements were defined at discharge by headache intensity compared with before hospitalization. RESULTS: Among 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 new daily persistent headache, 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 dihydroergotamine, 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 the second follow-up, 68 (81.9%) patients returned for follow-up on average of 71 days (range 10-283) after discharge. CONCLUSIONS: Our 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.

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.

Psychopharmacologic interventions for repetitive behaviors in autism spectrum disorders.

This article provides an overview of psychopharmacological treatments for repetitive behaviors in autism spectrum disorders (ASDs) in the context of current conceptualizations of this understudied core symptom domain. The available literature on the widely used selective serotonin reuptake inhibitors (SSRIs), including fluvoxamine, fluoxetine, citalopram, escitalopram, and sertraline, are reviewed. In addition to SSRIs, research on effects of other pharmacologic interventions such as divalproex sodium, risperidone, and the neuropeptide oxytocin are presented. To date, data are mixed for interventions commonly prescribed in clinical practice and suggest several areas of investigation in advancing research on the medication management of repetitive behaviors.