Data from a cohort of almost 5000 women seen at Montefiore Health System emergency departments suggest that primary headache, likely migraine, is underdiagnosed, and a high proportion of these women being of Black and Hispanic backgrounds.
New data from a study utilizing the Clinical Looking Glass, a clinical analytics program with data compiled from the Montefiore Health System, suggest that the majority of women of reproductive age who seek care for headache in the emergency department (ED) appear to have undiagnosed primary headache—and likely, migraine. Notably, a high proportion of these women were those of Hispanic and Black backgrounds.1
The study included 4996 women aged 29.4 years (±7.1) with last menstrual period (LMP) data who presented to a Montefiore ED with the primary complaint of headache, of which 53.1% self-identified as Hispanic, 33.9% as Black, and 5.6% as non-Hispanic White. Of those nearly 5000 women, only 17.7% had a prior diagnosis of migraine and only 3.1% had previously used a triptan. Only 0.2% received a first-time diagnosis of migraine, and 7.3% had a migraine diagnosis made after ED visit. Of note, the highest volume of ED visits in the dataset, equaling 7% of visits, occurred during the first day of menses.
Coinvestigators Crystal Jicha, MD, fellow, Montefiore Headache Center; and Jelena Pavlovic, MD, PhD, associate professor, The Saul R. Korey Department of Neurology, Montefiore Medical Center, conducted the study to assess the characteristics and ED management of headache in reproductive-age women. Jicha presented data at the 2022 American Headache Society (AHS) Annual Scientific Meeting, June 9-11, in Denver, Colorado.
“Are we missing migraine? Clearly, there is a high proportion of undiagnosed migraine in this diverse patient population,” Jicha said in her presentation. “First, [there were] few women with previous diagnoses of migraine, and few women had received triptans in the past. Another point to share about why this is likely migraine disease that we’re missing in the large majority is that many women presented during menses, which is a known time of migraine worsening, both in severity and frequency. And a high proportion of those in the hospital were given antiemetics, which suggests they had nausea—which is obviously something we see in migraine disease. So, we’re likely missing a lot of migraine, both in the ambulatory care setting as well as in the emergency department.”
Antiemetics were administered to 50.8% of the cohort, while NSAIDs were given to 34.5%. Diphenhydramine was given to 29.2%, and opioids to 4.0%. At the time of discharge, 8.6% of the women were prescribed triptans and just 0.1% received preventative treatments.
When breaking down medication prescriptions by race, those of non-Hispanic White background received triptans and preventives at the highest rate, 1.8%, compared with 0.9% of Black women and 0.8% of Hispanic women. NSAIDs were given to 9.3% of non-Hispanic White women, compared with 13.7% of Black women and 12.5% of Hispanic women. A migraine diagnosis was made after ED presentation for 14.3% of non-Hispanic White women compared with 12.2% of Black and 17.9% of Hispanic women.
“The second question is: are we providing adequate ED care? Adequate care requires adequate diagnosis, and again, few women received migraine diagnoses during their ED stay or after their ED visit,” Jicha explained. “So, we’re not diagnosing these women with migraine and, therefore, they’re not receiving the treatments that they should be. Minimal medications were prescribed upon discharge—the most common of which were NSAIDs. Triptans, again, were not commonly prescribed, but they were more common amongst those of non-Hispanic White background and very few preventives were prescribed, which I think is on par with what Dr. [Larry Charleston, IV, MD, MS, FAHS] had presented earlier.”
Charleston, a professor and the director of the Headache & Facial Pain Division at Michigan State University College of Human Medicine, gave the Seymour Solomon Award Lecture at AHS, speaking to the exploration of race, racism, race-based headache disparities, and professional ethics in the care of this patient population. Ultimately, he offered strategies to better understand and mitigate race-based disparities and inequities in headache medicine. In his lecture, Charleston spoke of the so-called “Golden Rule” principle, and how its application to the challenges of racial disparities can be a step in the right direction.2
“You want people to understand you? You’ve got to try to understand other people. This Golden Rule principle, I think, can be a step that all of us can take because it’s really the whole headache community. This is something we have to overcome together,” Charleston said. Jicha echoed some of this sentiment. Asking why migraine was not being diagnosed and why medications that are specific to migraine were not being prescribed, she said, in part, because of “both explicit and implicit biases in the medical community.
“This is an issue that we’re really just starting to explore and is of importance not only in our own personal practices but also in the medical community at large. We need to do a better job of diagnosing migraine, and hopefully, that will lead to better treatment options for not only those of non-Hispanic White background but also those of different racial backgrounds,” Jicha said.