Implementing Headache Training in Residency

NeurologyLiveJune 2023
Volume 6
Issue 3

Despite a tremendous burden regarding migraine-related disability and expenditure, headache disorders remain underdiagnosed and undertreated, and only a small percentage of patients report satisfaction with the treatment received.

Melissa Rayhill, MD, FAHS, FAAN

Melissa Rayhill, MD, FAHS, FAAN

Ashley Alex, MD

Ashley Alex, MD

HEADACHE DISORDERS RANK 14TH among global causes of disability-adjusted life-years for all ages and genders—second among women aged 15 to 49 years1—and are among the most common causes of outpatient neurology visits. When considering migraine disease specifically, patients with this disorder had total annual costs (both direct and indirect) of approximately $8924 higher than demographically similar individuals without migraine.2 Yet, despite this tremendous burden regarding disability and expenditure, headache disorders remain underdiagnosed and undertreated, with only a small percentage of patients satisfied with the treatment received.

Although limitations in treatment modalities are important to consider here, we must also discuss deficiencies in outpatient neurology training, and specifically headache medicine education, as contributory.3 Although neurology is predominantly outpatient based, only 20% of total training is geared toward this.4 Multiple cross-sectional surveys help to depict the variable quality of education offered. Gallagher et al found that 88% of medical schools reported adequate headache exposure, with 92% reporting no plans to increase hours of headache education. However, when neurology and family medicine program directors were surveyed, 68% reported that their incoming residents had an insufficient foundation of knowledge.5

Neurology residency programs have changed significantly over the past few decades, likely in part related to the development of headache medicine fellowship programs. In a 2005 study, only 29% of neurology department chairs and program directors reported adequate teaching of headache diagnosis and management.6 In contrast, a 2016 study revealed that 96% of program directors and 87% of chief residents believed neurology residents were adequately prepared to diagnose and treat headache disorders upon graduation. Of note, despite this dramatic improvement, approximately a quarter of program directors still planned to increase the number of lectures and clinic time dedicated to headache.7 Beyond resident lectures, headache remains one of the least common specialties represented at grand rounds,8 which may reflect lower National Institutes of Health funding in headache research and fewer grant-funded faculty and research scientists.9 In addition, although approximately 90% of programs provide exposure to procedures, less than 25% report formal trainee credentialing.10

At the University at Buffalo Jacobs School of Medicine and Biomedical Sciences, The State University of New York, we have implemented our curriculum in headache medicine using multiple modalities throughout our categorical adult neurology residency program (TABLE). At the end of intern year, residents go through “boot camp” training to ease the transition from internal medicine into neurology. As part of this 4-week module, residents have a week of intensive didactic lectures focused on acute neurological conditions, including identification and management of headache emergencies. We also use a state-of-the-art simulation center to give immediate and specific feedback on management of emergent causes of acute headache, including intracranial hemorrhage and its complications. Once residents have started neurology, we continue to incorporate headache into scheduled didactic lectures, focusing on both primary and secondary headache disorders. We also schedule journal club sessions and case conferences, highlighting clinical pearls and navigating challenging decision trees for trainees. Trainees are encouraged to seek additional elective and/or research time and are urged to attend conferences in headache medicine.

The best way for most of us to learn is to have hands-on experience caring for patients with headache. Residents gain experience treating patients with headache syndromes in the emergency department and on inpatient floors, including the use of intravenous therapies such as dihydroergotamine and subcutaneous peripheral nerve blocks. On the outpatient side, all residents rotate through our subspecialty headache medicine clinics. Here they gain experience with performing peripheral nerve blocks, onabotulinum toxin A injections, trigger point injections, and subcutaneous injections of calcitonin gene-related peptide monoclonal antibodies. Perhaps the most meaningful exposure in outpatient headache medicine is in weekly resident continuity clinics, where residents have the most autonomy and longitudinal experiences caring for patients with headaches.

Opportunities for Headache Medicine Education Implementation at the University at Buffalo Jacobs School of Medicine and Biomedical Sciences Adult Neurology Residency Program

(click to enlarge)

Like all other neurology residency programs, our program was affected by the COVID-19 global pandemic. The pandemic had a sweeping impact on every aspect of resident education, but it particularly limited exposure to outpatient subspecialty training. Procedure-based education was stopped/limited in the early days, as well. We are still struggling to adequately assess residents in headache medicine, and identifying educational gaps specifically caused by the pandemic is an ongoing challenge. This was made only more challenging with the removal of subspecialty-specific Accreditation Council for Graduate Medical Education milestones in 2021.11 In addition, there was a significant decrease of in-person scientific and educational meetings during this time, resulting in limited in-person networking, mentoring, and social opportunities.

Still, most would agree that there were some silver linings. The ubiquitous use of virtual communication platforms increased flexibility for the delivery of educational sessions, improved access to national meeting content for trainees, and increased geographically distant and institutionally diverse collaboration. We experienced larger audiences for grand rounds and lectures with international speakers from diverse fields, including headache medicine. In addition, all our trainees acquired a skill set in telemedicine during their continuity clinics that they would have otherwise not been exposed to with any regularity.12

The American Headache Society has numerous resources to aid in increasing quality education through improved subspecialty exposure.13 The Resident Education for Assessment and Care for Headache (REACH) program provides a foundation to educate residents through a half-day curriculum, including grand rounds, small education modules, and online elements. This is especially advantageous for neurology programs without headache-trained faculty. In addition to this, REACH helps to inspire first- and second-year residents to pursue careers in headache medicine during a weekend session with renowned faculty. The International Headache Academy also provides the opportunity for early-career neurologists to use problem-solving and evidence-based research to elucidate thought-provoking clinical and research situations while also networking with colleagues and experts. There are also numerous national and regional conferences that can contribute to career advancement, knowledge of newer treatments/interventions, and better outcomes.

Given the substantial unmet needs of patients with headache disorders, it is imperative to address this issue by inspiring and educating neurology residents about this significant health burden. As we have demonstrated at our own institution, there are many avenues by which headache medicine education can be incorporated into the curriculum. By increasing didactic lectures and formalizing procedural training, despite the current paucity of headache specialists, general neurologists may be able to garner the skills needed to treat one of the most common conditions encountered in outpatient clinics. We can emphasize multidisciplinary approaches as well as effective attention and communication that will allow patients to feel heard and respected, thus leading to better outcomes and satisfaction.

1. Steiner TJ, Stovner LJ, Jensen R, Uluduz D, Katsarava Z; Lifting The Burden: the Global Campaign against Headache. Migraine remains second among the world’s causes of disability, and first among young women: findings from GBD2019. J Headache Pain. 2020;21(1):137. doi:10.1186/s10194-020-01208-0
2. Bonafede M, Sapra S, Shah N, Tepper S, Cappell K, Desai P. Direct and indirect healthcare resource utilization and costs among migraine patients in the United States. Headache. 2018;58(5):700-714. doi:10.1111/head.13275
3. Begasse de Dhaem O, Burch R, Rosen N, Shubin Stein K, Loder E, Shapiro RE. Workforce gap analysis in the field of headache medicine in the United States. Headache. 2020;60(2):478-481. doi:10.1111/head.13752
4. Klebanoff LM, Safdieh JE. Modern neurology training is failing outpatients. JAMA Neurol. 2023;80(4):333-334. doi:10.1001/jamaneurol.2022.5490
5. Gallagher RM, Alam R, Shah S, Mueller L, Rogers JJ. Headache in medical education: medical schools, neurology and family practice residencies. Headache. 2005;45(7):866-873. doi:10.1111/j.1526-4610.2005.05155.x 
6. Kommineni M, Finkel AG. Teaching headache in America: survey of neurology chairs and residency directors. Headache. 2005;45(7):862-865. doi:10.1111/j.1526-4610.2005.05154.x
7. Ahmed ZA, Faulkner LR. Headache education in adult neurology residency: a survey of program directors and chief residents. Headache. 2016;56(5):871-877. doi:10.1111/head.12822
8. Burish MJ, Ahmed ZA, Rosen NL, Halker Singh RB. Grand rounds education in neurology, with a focus on headache medicine. Headache. 2021;61(7):1077-1085. doi:10.1111/head.14116
9. Vollbracht S, Masters-Israilov A. The unmet need of headache medicine grand rounds education in neurology. Headache. 2021;61(7):988-989. doi:10.1111/head.14149
10. Robbins MS, Robertson CE, Ailani J, Levin M, Friedman DI, Dodick DW. Procedural headache medicine in neurology residency training: a survey of US program directors. Headache. 2016;56(1):79-85. doi:10.1111/head.12695
11. Barratt D, Chiota-McCollum N, Dewey J, et al. Neurology milestones. Accreditation Council for Graduate Medical Education. July 1, 2021. Accessed May 1, 2023.
12. Rayhill ML, Rosen N, Robbins MS. Headache education adaptation during the COVID-19 pandemic: impact on undergraduate and graduate medical education. Curr Pain Headache Rep. 2022;26(11):827-833. doi:10.1007/s11916-022-01084-0
13. 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(8):1092-1101. doi:10.1111/head.12623
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