Headache Disparities in African-Americans in the United States: A Narrative Review

Unique Considerations in Episodic Migraine: Underserved Populations

PURPOSE OF REVIEW

Episodic migraine is a common and disabling neurological disorder that is underdiagnosed and undertreated. Additional barriers are put in place for those who belong to an underserved population. This could be based on race, ethnicity, gender, sexual orientation, or socioeconomic status.

RECENT FINDINGS

There has been a lot of interest in understanding the extent of these disparities, but studies for many of these groups are lacking. More work is needed to understand the disparities and needs of underserved populations. Most of the literature has been done for Black populations but there are many other underserved communities that need assessment and intervention. The healthcare community needs to take action to improve support for populations with a higher incidence of migraine and disability, yet a lower rate of diagnosis and treatment. Some recommendations include awareness of biases, systemic changes, education, and including diverse populations in research and training.

A historical review of pain disparities research: Advancing toward health equity and empowerment

BACKGROUND AND PURPOSE

This theory-guided review draws on 30 years of published data to examine and interrogate the current and future state of pain disparities research.

METHODS

Using the Hierarchy of Health Disparity Research framework, we synthesize and present an overview of "three generations" of pain disparities scholarship, while proposing directions for adopting a "fourth generation" that redefines, explains, and theorizes future pain disparities research in a diverse society.

DISCUSSION

Prior research has focused on describing the scope of disparities, and throughout the historical context of human existence, racialized groups have been subjected to inadequate pain care. It is imperative that research not only illuminates existing problems but also provides solutions that can be implemented and sustained across varying social milieus.

CONCLUSION

We must invest in new theoretical models that expand on current perspectives and ideals that position all individuals at the forefront of justice and equity in their health.

Efficacy and safety of eptinezumab for migraine prevention in patients with prior preventive treatment failures: subgroup analysis of the randomized, placebo-controlled DELIVER study

BACKGROUND

Migraine is a disabling neurological disease adversely affecting many aspects of life. Most patients are still required to have failed several older oral preventive therapies before being reimbursed for a preventive, migraine-specific anti-calcitonin gene-related peptide treatment. In the 24-week placebo-controlled portion of DELIVER, eptinezumab was shown to reduce migraine frequency and resulted in higher migraine responder rates compared with placebo in patients with two to four previous preventive treatment failures. This subgroup analysis assessed if demographic or clinical characteristics were associated with differences in preventive benefits.

METHODS

Migraine frequency reductions and responder rates (i.e., the proportion of patients reaching a ≥50% and ≥75% reduction in monthly migraine days relative to baseline) were determined in the total population and predefined subgroups by sex, age, migraine frequency (chronic migraine, episodic migraine, high-frequency episodic migraine, low-frequency episodic migraine), medication overuse, medication-overuse headache, and previous preventive treatment failures (2, >2). The primary endpoint was change from baseline in monthly migraine days over weeks 1-12.

RESULTS

Eptinezumab 100 and 300 mg reduced monthly migraine days more than placebo over weeks 1-12 (-4.8 and -5.3 vs -2.1, respectively; p < 0.0001). In most subgroups, eptinezumab-treated patients demonstrated larger monthly migraine days reductions from baseline over weeks 1-12 than patients receiving placebo, with reductions maintained or increased over weeks 13-24. For ≥50% and ≥75% migraine responder rates, the odds ratios versus placebo all numerically favored eptinezumab.

CONCLUSION

Eptinezumab had larger monthly migraine days reductions and higher responder rates than placebo across clinically relevant subgroups showing that, across different demographic populations and clinical characteristics, eptinezumab is effective in patients with migraine and prior preventive treatment failures.Trial Registration: ClinicalTrials.gov (Identifier: NCT04418765).

Addressing inequities in headache care by embedding services in a community health center in Boston, MA

There is a critical need to diagnose and treat headache disorders in primary care settings. This is especially true for those who face systemic barriers to healthcare access due to racism or poverty. In order to target those at higher risk of disability associated with neurologic disease in our healthcare system, we embedded a specialized headache and neurology clinic within the Brigham and Women's Hospital Southern Jamaica Plain Community Health Center in Boston, MA. The goal was to create a sustainable, integrated clinic consistent with the CHC's racial justice mission, with an emphasis on equitable care, awareness of structural barriers to care, improved communication with primary care and inclusion of trainees as important members of a healthcare team. In its' first year, the clinic had over 400 patient visits, with a near-perfect rate of completion of consults. In addition to improved access to tertiary care headache services, successes have included improving continuity of care, cultivating a model of shared care with primary care practitioners and stimulating interest in headache medicine among staff and trainees. Challenges have included the use of staff time to complete prior authorizations, and the need to find or develop Spanish-language and culturally appropriate patient educational resources. By providing care within the patient's medical home, the headache specialist gains a deeper appreciation of a patient's social determinants of health and can readily access resources to navigate barriers. The personal and professional fulfillment that headache specialists may experience while doing this important work could help protect against burnout. Sustainability depends on ensuring equitable provider reimbursement; departmental and institutional support is essential. We believe this clinic can serve as a model for specialists throughout the United States who wish to improve the delivery of care to patient populations who face access barriers.

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.

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.