Migraine’s “Supply:Demand” Problem...and How to Fix it: A public health bottleneck
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Very few chronic medical disorders exert more of a negative impact on the public health than does migraine. The World Health Organization ranks migraine second globally on the list of the chronic medical disorders that produce disability and reduce quality of life. For the young female population, migraine is first on that list.
How can this be? Migraine rarely kills or inflicts permanent neurologic, cardiovascular or other systemic injury. After all, it’s “just a headache”, right?
Wrong. First of all, migraine is often much more than “just a headache”, and even when headache alone is considered, thousands of days of productive living are lost to American citizens each year because of functionally incapacitating migraine headache. If you spend a “migraine day” closeted in a darkened room, unable to function and miserable with pain, nausea and other common accompanying symptoms, for that day you might as well be dead. Each and every day, as many Americans are transiently “dead” with migraine as perished in the entire Vietnam conflict.
Two major factors account for migraine’s tremendous impact on public health. First, migraine is astoundingly prevalent. Approximately 12% of the American population, almost 40 million citizens, have active migraine, and 1 in 50 have chronic migraine (a variant of the disorder that is associated with a lower quality of life and higher level of healthcare resource utilization than the more common episodic form). With this high prevalence, adding together the emotional, social and economic costs of migraine associated with each individual case yields total sums that are jaw-droppingly high.
Second, despite the tremendous advances made in our understanding of migraine’s biology, the emergence of so many new treatments that are effective in managing the disorder, and the efforts that have been made to heighten awareness of migraine in the general population and the community of healthcare providers (HCPs), many millions of migraineurs remain undiagnosed, misdiagnosed, untreated or treated inadequately. Sequential research studies addressing the issue found that the number of American migraineurs seeking and receiving medical care for their headache disorder has not increased substantially.
Of the roughly 40 million Americans with active migraine, how many would benefit from seeing a HCP? This is not a number easily calculated, but data from meticulously conducted epidemiologic research suggest that over 38% percent of migraineurs - about 15 million individuals - currently have a migraine burden sufficient to justify a course of headache prevention therapy; of that subgroup, only about 13% are receiving such therapy. As regards chronic migraine, the common variant of migraine which exerts a disproportionately negative effect on the public health, results from the CaMEO Study indicated that <5% percent have been evaluated for their headache disorder by an HCP, have received an accurate diagnosis and have been appropriately treated.
Even with our increased knowledge of what causes migraine and the consequent introduction of exciting new “designer drugs” for migraine’s for treatment, many who would benefit from those therapies never see an HCP or do not experience a positive result from their medical evaluation. Granted, not every migraineur requires assistance from an HCP; those who experience a handful of non- incapacitating migraine episodes annually and whose headaches respond consistently and well to aspirin, acetaminophen or Excedrin typically do not require medical attention. On the other hand, all migraineurs with high frequency episodic migraine (9 to 14 headache days per month) or chronic migraine (15 or more days per month) typically do deserve evaluation by an informed HCP, as do most migraineurs with mid-frequency episodic migraine (4 to 8 headache days per month) or any migraineur who is experiencing functionally incapacitating migraine episodes on a monthly or near monthly basis.
In summary, despite the dramatic increase in migraine awareness and the tremendous improvement in migraine therapeutics that has occurred over the past 30 years, we still are making only a modest dent in the public health burden imposed by migraine.
Why? The potential answers are legion, but difficult to ignore is the medical community’s enduring disinclination to regard migraine as being a medical disorder worthy of attention. This “just a headache” attitude is pervasive amongst HCPs engaged both in medical training and clinical practice. Migraine remains the most common neurologic disorder prompting an individual to seek medical attention and ranks first amongst the disorders encountered by neurologists working in clinics. Despite this, and even quite recently, I have served as a member of the neurology faculty in medical schools where the curriculum for students and even for neurology residents contained no required formal clinical rotation focused on headache. Too often, headache - and migraine in particular - remains an afterthought within the realm of medical education.
Not surprising then that there exist relatively few physicians with the training, experience and inclination required to manage migraine effectively. Confronting that relative handful of physicians is an enormous population of migraineurs. The result: a staggeringly huge and persisting problem of inadequate supply (physicians) vs overwhelming demand (migraineurs in need of care). It’s like trying to find a nice but inexpensive apartment near Central Park: precious few exist, and the market for such a rarity is vast.
Well-intentioned efforts to increase public awareness of migraine - this magazine serving as an obvious example - will only add fuel to the supply:demand fire. As more and more migraineurs seek medical attention from a static pool of subspecialists, accessibility to care becomes yet more of a problem. At one university medical center where I worked for some years, the wait time for a new patient appointment hovered around one year. This is ridiculous. Especially for chronic migraine, a disorder which appears to become increasingly resistant to effective treatment if such treatment is delayed, imposing a one year waiting period for those migraineurs motivated to seek attention obviously works against therapeutic success and the patient’s best interests.
So how can migraine’s supply:demand problem be fixed? Even if the existing pool of physicians who specialize in headache worked 24/7, the effect on the supply:demand problem would be negligible. We could increase that pool by training more students and residents to become competent in the practice of headache medicine and, more specifically, by increasing the number of existing post-residency headache fellowship programs. While many would argue that these efforts are likely to bear much fruit, there exists a stubborn resistance to change within the culture of American medical training. Also an obstacle is the fact that economic self interest is drawing medical school graduates to higher-earning specialties such as orthopedic surgery, plastic surgery, cardiology, ophthalmology and gastroenterology rather than neurology…let alone neurology with a subspecialty focus on headache. That’s great for those of us who break a bone, require cataract extraction or desire better skin and cosmetic enhancement, but it does nothing to help those 40 million American migraineurs.
The development of telemedicine accelerated dramatically following the onset of the COVID pandemic, and with its strong emphasis on verbal communication telemedicine lends itself especially well to the practice of headache medicine. Unfortunately, in addressing the supply:demand problem associated with migraine, telemedicine is something of a double-edged sword. While it may be that more patients can be seen more efficiently via telemedicine, any increase in efficiency tends to be balanced by improved access and a corresponding increase in patient volume. Without question, telemedicine has made an invaluable contribution to the practice of headache medicine, but expanding provider access to migraineurs who otherwise might not seek medical attention will not solve the supply:demand problem.
More promising is the prospect of increasing the supply side (ie, the number of providers) by the recruitment of “physician extenders”. It seems clear from simple observation that “advanced practice providers” (APPs: nurse practitioners and physician assistants) can be trained to serve as highly effective headache subspecialists. While regulations regarding the degree of supervision required vary widely from state to state, there currently are a number of nurse practitioners who manage clinical/clinical research programs in headache at a high level of competence and do so working independent or largely independent of any supervising physician. This has occurred in the absence of any formal, standardized training programs devoted to APPs seeking particular expertise in the field of headache medicine, and if such programs were established the resulting increase in the number of headache subspecialists available could go a long ways towards helping to resolve headache’s supply:demand problem.
Even more intriguing is the prospect of using artificial intelligence (AI) to augment HCP-associated headache management. In a previous issue of this magazine we described how one electronic algorithm under development at Stanford and UCLA may be effective in both headache diagnosis and in offering patients assistance with migraine management. With continued development such algorithms could evolve into “smart programs” that learn from experience. As with a human provider, feedback data resulting from implementation of algorithm-generated diagnoses and management plans could be expected progressively to improve the reliability and effectiveness of the program.
Finally, education of patients intended to increase active participation in their own migraine care could relieve much of the management burden currently born by HCPs. As one example, six years ago this magazine was conceived to serve just that purpose: to provide patients with a greater understanding of migraine and its treatment than they could expect to receive and absorb during the course of a clinic visit. The Table illustrates how this magazine can be put to use to enhance provider:patient communication, improve compliance, increase patient satisfaction and produce a more positive clinical outcome.
Yes, supply:demand is a problem in headache medicine, but there exist these and other creative solutions which can serve to mitigate that problem. Rather than simply moan about existing and impending physician shortages, it’s time to get creative.
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