Mia Minen, MD, MPHMia Minen, MD, MPH
Headache disorders are extremely common and can be very disabling. Tension-type headache and migraine alone are the second and third most prevalent disorders in the world.1 Migraine is also the second most disabling condition globally2 and the most common cause of disability in patients below the age of 50.3 Within the US, 12% of the population are affected by migraine alone.4

While it is an exciting time for the field of headache medicine, with many effective treatments already in existence for headache disorders and more emerging treatments on the horizon, proper diagnosis of headache disorders and subsequent delivery of appropriate treatments are imperative to alleviate the population burden of headache disorders. Unfortunately, the diagnosis rate of headache disorders is below 40%,5 and treatments for headache by nonspecialists can deviate from current evidence-based guidelines and are therefore suboptimal.6

Our patients have a huge need for access to specialists, yet unfortunately, there is a huge shortage of headache specialists. In fact, the demand for headache medicine specialists is likely to outpace the supply compared to other neurology subspecialties. For example, there are an estimated 404 multiple sclerosis (MS) subspecialists in the US7 for an estimated MS population of approximately 700,000.8 This translates to a patient-specialist ratio of roughly 1750:1. In contrast, even in the Northeastern US, where there is the highest concentration of headache specialists, there are 123 headache specialists for an expected population of over 5.5 million affected by migraine alone, for an overwhelming patient-specialist ratio of 45,343:1.9 Thus, ensuring an adequate number of providers with specialty training in headache medicine, ideally in structured headache centers10 is needed to improve quality outcomes of headache disorders.

An increasing number of neurology residents are interested in headache medicine fellowship training.11,12 Nevertheless, certain myths still persist. The perceptions that headache medicine is not “hardcore enough” and headache seems more “psychogenic” are identified as the most influential barriers to headache medicine education during residency.13 Increased early exposure to headache medicine could help battle this trend. One reason for the persistence of this myth may be due to difficulties in correctly diagnosing a headache disorder and finding effective treatments. Studies suggest that the current undergraduate and residency training does not appear to adequately prepare trainees for managing headache disorders. However, studies show that the top reasons people choose to go into headache medicine are because they had a mentor in the field (65%), liked the patient population (53%), and worked in a headache center (41%). Thus, exposure to headache medicine specialists is key for mentorship and understanding and helping treat headache center patients.

How can this be done?
  1. Look up the headache specialists closest to you. Most of us would be happy to speak with you and if allowed by our institutions/office practice, have you spend time with us in our headache practice. Please note that since there is such a shortage of us, many states do not have a headache medicine specialist, so travel or tele-communication may or may not be necessary.
  2. Join the American Headache Society Mentorship in Headache Luncheon at the annual American Academy of Neurology meetings
  3. Consider asking your department for headache grand rounds speakers if they do not have them on the schedule already. Feel free to write to the speaker to see if you might be able to grab a cup of coffee before or after the talk.
  4. Consider applying for any of the headache training programs: The American Headache Society Resident Education Program if you are a more junior resident or the International Headache Academy Program if you are more advanced.
  5. See if you can help bring the American Headache Society half-day Resident Education for Assessment and Care for Headache (REACH) program to your institution if you do not have a headache center.
  6. Obtain a trainee membership to the American Headache Society.
  7. Attend an American Headache Society meeting (either the Scottsdale Symposium or the annual Scientific meeting). If you do this, be sure to attend the New Investigator and Trainee (NIT) Special Interest Group meeting.

Mia Minen, MD, MPH, is currently Chief of Headache Research at NYU Langone Health. She serves as the Chair of the Special Interest Sections of the American Headache Society. In addition, she is on the membership, education, and guidelines committees of the American Headache Society. Minen was also active in the New Investigator and Trainees Section of the American Headache Society. She led the study titled, “New Investigator and Trainee Task Force Survey on the Recruitment and Retention of Headache Specialists.”

Hao Huang, MD, attended Boston University School of Medicine and is currently a fourth year neurology resident at NYU. He will be pursuing a Headache Medicine Fellowship at NYU and is looking forward to becoming a headache specialist in the future.
REFERENCES
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2. Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet. 2017;390(10100):1211-1259. doi: 10.1016/S0140-6736(17)32154-2
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7. Halpern MT, Kane H, Teixeira-poit S, et al. Projecting the Adequacy of the Multiple Sclerosis Neurologist Workforce. Int J MS Care. 2018;20(1):35-43. doi:10.7224/1537-2073.2016-044
8. Wallin MT, Culpepper WJ, Campbell JD, et al. The prevalence of MS in the United States: A population-based estimate using health claims data. Neurology. 2019;92(10):e1029-e1040. doi: 10.1212/WNL.0000000000007035
9. Mauser ED, Rosen NL. So many migraines, so few subspecialists: analysis of the geographic location of United Council for Neurologic Subspecialties (UCNS) certified headache subspecialists compared to United States headache demographics. Headache. 2014;54(8):1347-57. doi:10.1111/head.12406
10. Steiner TJ, Göbel H, Jensen R, et al. Headache service quality: the role of specialized headache centres within structured headache services, and suggested standards and criteria as centres of excellence. J Headache Pain. 2019;20(1):24. doi:10.1186/s10194-019-0970-7
11. Johnson et al 2012: Johnson NE, Maas MB, Coleman M, Jozefowicz R, Engstrom J. Education research: Neurology training reassessed. The 2011 American Academy of Neurology resident survey results. Neurology. 2012;79:1831-1834.
12. Mahajan et al 2019: Mahajan A, Cahill C, Scharf E, et al. Neurology residency training in 2017: A survey of preparation, perspectives, and plans. Neurology. 2019;92:76-83.
13. Minen et al 2015: Minen MT, Monteith T, Strauss LD, Starling A. New investigator and trainee task force survey on the recruitment and retention of headache specialists. Headache 2015; 55: 1092–1101.