National Analysis Reveals Certified Headache Specialists Absent From More Than 90% of US Counties

More than 9 in 10 US counties have no clinicians in headache medicine certified by the United Council for Neurologic Subspecialties (UCNS), according to a new cross-sectional geospatial workforce analysis published in Headache. The study reported that certified headache subspecialty care is concentrated almost exclusively in large metropolitan counties, with availability dropping sharply in areas marked by greater socioeconomic deprivation and social vulnerability, gaps that state- and region-level reporting have previously obscured.¹ 

“For a patient living in a county without a certified headache specialist, care can become fragmented. They either receive it through their family physician, general neurologists, or even emergency medicine practitioners,” lead author Bradley Ong, MD, a neurologist at Cleveland Clinic, told NeurologyLive^®. “If subspecialty input is really needed, they often can also travel outside their county/state, or rely on telemedicine. That said, not every patient with headache disorder requires subspecialty care. The concern is whether patients with refractory, high-disability, or diagnostically uncertain headache disorders have a clear pathway to escalate their care.”

“In our study, around 91.3% of US counties had no verified headache specialist, and around 66.3% had no neurologist at all. In those communities, even identifying which patients need subspecialty care and connecting them to the appropriate clinician may be difficult. On caveat here is that our study mapped local workforce availability rather than individual patients; therefore, we cannot say exactly where patients ultimately received care and/or whether they were underrated,” Ong added.

Widespread Gaps in Local Coverage

Using the publicly available UCNS diplomate roster as of January 7, 2026, investigators identified 797 actively certified headache specialists with assignable practice locations across the 50 states and Washington, DC. Mapping those locations to all 3144 US counties, the team reported that 2870 counties (91.3%) had 0 UCNS-certified headache specialists, compared with 121 of 306 hospital referral regions (HRRs, 39.5%) and just 2 of 51 states (3.9%). Only 142 counties (4.5%) had a single specialist, and just 87 (2.8%) had 3 or more.

The county-level median density of headache specialists was zero per 100,000 adults; among counties with at least 1 specialist, median density was 0.40 per 100,000. The disparity was not simply a function of low overall neurology supply, though it was closely tied to it. Headache specialists were completely absent from every county lacking a general neurologist, and 2085 counties (66.3%) had no neurologist of any kind on record in National Provider Identifier registry data.

Deprivation, Social Vulnerability, and Migraine Burden

Investigators also modeled specialist availability against county-level socioeconomic deprivation and social vulnerability using mixed-effects negative binomial regression, adjusting for neurologist density, urbanicity, US Census region, and within-state clustering. Each 10-point increase in Area Deprivation Index score was associated with a 13% lower expected headache specialist rate (adjusted incidence rate ratio [aIRR], 0.87; 95% CI, 0.82-0.93; P <.001).

Each 0.1-unit increase in Social Vulnerability Index score was associated with a 6% lower expected rate (aIRR, 0.94; 95% CI, 0.90-0.98; P = .003). Metropolitan counties of every population size had significantly higher adjusted specialist rates than nonmetropolitan counties, and counties in the South and West had lower adjusted rates than those in the Northeast.

READ MORE: American Academy of Neurology, American Headache Society Issue Updated Guideline on Migraine Prevention

To contextualize local supply against need, the authors applied a national adult migraine prevalence estimate of 12% to calculate a specialist-to-burden ratio. Olmsted County, Minnesota, home to the Mayo Clinic, had the most favorable ratio among counties with at least one specialist, at 59.02 specialists per 100,000 estimated adults with migraine. By contrast, large, populous counties including Fresno County, California; Fulton County, Georgia; and Wake County, North Carolina, each had only a single certified specialist despite estimated migraine populations exceeding 240,000 adults.

What the Findings Mean for Access

The authors emphasized that county-level absence reflects lack of a local specialist rather than proof that subspecialty care is unreachable in a clinically meaningful travel radius, since patients often cross county or state lines for care and a single specialist may serve a multicounty catchment. Even so, they noted that prior Medicare-based data have shown nearly 1 in 5 neurology patients travel at least 50 miles one way for care, with substantially greater burden in rural, low-density regions, suggesting travel burden compounds the supply gaps identified here.²

The findings echo previously documented clustering patterns among neurologists and epilepsy subspecialists in metropolitan, higher-resourced areas.^3,4 All told, the authors argued that closing local access gaps in headache medicine will require parallel investment in the broader general neurology workforce, not subspecialty growth alone, alongside targeted workforce incentives, expansion of tele-headache services, and integration of headache expertise into regional referral hubs. They noted that telemedicine, endorsed by the American Headache Society as safe and effective for follow-up and medication management, may help bridge, though not fully resolve, gaps in counties where general neurology infrastructure exists but subspecialty presence does not.

“The fastest way to ‘bridge’ the immediate subspecialty gap is probably telemedicine, particularly in communities where primary care/general neurology infrastructure already exists. It can extend headache specialist input for consultation, medication management, and follow-up without waiting for a new specialist to be trained or recruited. However, the best way to improve headache care overall is likely a layered model,” Ong added. “Primary care clinicians and general neurologists can manage many patients locally, while tele-headache programs and regional referral hubs provide support for more complex cases.”

“Telemedicine is a bridge, not a complete replacement for local care. It cannot provide procedures, infusion therapies, or all of the in-person support that some patients require, and it is less effective in areas that lack basic neurology infrastructure. I think in the near future, telemedicine combined with stronger regional referral networks would probably have the quickest impact,” Ong told NeurologyLive.

Study Limitations

Limitations included reliance on a uniform national migraine prevalence estimate that does not capture regional variation in prevalence or care-seeking behavior, the cross-sectional design, and the absence of drive-time or claims-based analyses that could more directly quantify patient-level access burden. The authors also did not classify specialists by practice setting (academic, health-system, or private practice) or capture noncertified clinicians, including general neurologists and primary care physicians, who provide substantial headache care outside UCNS certification.

“Our findings suggest that this is not simply a matter of headache specialists following the existing neurology workforce. The association between socioeconomic disadvantage and lower headache specialist availability remained even after accounting for neurologist density, urbanicity, geographic region, and population size,” Ong told NeurologyLive. “Our study did not survey physicians about why they chose a particular practice location, so we cannot assign a single cause. However, headache subspecialty practice often depends on a broader clinical ecosystem (I.e. referral networks, infusion and procedural support, fellowship training, health-system infrastructure, etc.).”

“These resources are more commonly available in large metropolitan health systems and academic centers,” Ong continued. “The pattern therefore appears to be structural rather than a matter of individual clinicians simply choosing not to work in disadvantaged communities. Areas with fewer resources may have greater difficulty recruiting and sustaining a subspecialty practice, even after accounting for the number of neurologists already present.”

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REFERENCES
1. Ong B, Thompson N, Mueller H, Starling AJ, Cheng N. Geographic variation in certified headache subspecialty availability in the United States. Headache. 2026;00:1-14. doi:10.1111/head.70197
2. Lin CC, Hill CE, Kerber KA, et al. Patient travel distance to neurologist visits. Neurology. 2023;101(18):e1807-e1820. doi:10.1212/WNL.0000000000207810
3. Lin CC, Callaghan BC, Burke JF, et al. Geographic variation in neurologist density and neurologic care in the United States. Neurology. 2021;96(3):e309-e321. doi:10.1212/WNL.0000000000011276
4. 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):1347-1357. doi:10.1111/head.12406