Two patients have migraine: a Black patient and a White patient. Which person is more likely to get proper headache treatment?
The question is not hypothetical. A half-century after the passage of the Civil Rights Act, American society is still awakening to the extent to which people’s everyday experiences are affected by their
skin color. A growing body of research shows that your “race” impacts the quality of healthcare you receive. And as we’re beginning to uncover, that includes your headache and migraine care.
- Migraine in African-Americans is more frequent, more severe, more likely to be chronic and associated with more depression compared to non-Hispanic Whites.
Yet, among African- Americans with headache and migraine,
- Inaccurate diagnoses are more common
- Acute migraine attack medications are prescribed less frequently
- Lower-quality communication with physicians is reported
- Health care services for migraine treatment are less utilized
- Treatment plans are more likely to be abandoned
I am hopeful and an optimist by nature and believe that these racial disparities can be fixed. But to address the inequities, we first need to understand the problem.
A Growing Body of Research
When one group of people has a high burden of illness, injury, disability or mortality compared with another group, and those differences are preventable, that’s known as a disparity. Moreover, the terms “inequality” and “inequity” are sometimes confused but are not always interchangeable. Inequity refers to unfair, unjust, avoidable differences arising from poor governance, corruption or cultural exclusion. Inequality simply refers to the uneven distribution of health or health resources due to genetic, other factors, or the lack of resources.
Examples of disparities can be found across various communities across the United States. They can exist due to different variables including race, gender, socioeconomic status, age, location, disability status, or sexual orientation. In this article, the variable at hand is the social construct of race, and I’ll focus on the growing body of research on disparities faced by Black people.
The racial disparities in migraine care that researchers like me are beginning to uncover is part of a larger healthcare problem. We’ve long known, for example, that pregnancy-related deaths among Black, American Indian and Alaskan Native women are at least four times higher than their White peers. Blacks receive worse healthcare than Whites in 40% of healthcare quality measures. The COVID-19 pandemic, whose victims are disproportionately members of historically marginalized racial/ethnic groups, has further illustrated the disparities: One large recent study in Louisiana found that 76.9% of patients who were hospitalized with COVID-19 and 70.6% of those who died, were Black — even though Black patients only make up 31% of the health system.
Why do Black patients receive worse headache care?
There are many possible intertwined reasons why Black migraine patients receive inferior care. Here are some intriguing factors at play.
Fewer Black patients are seeking headache care. The number of Black patients receiving outpatient headache treatment is lower than the number you’d expect from population and prevalence statistics. That could be chalked up to a few possibilities:
- Lack of migraine knowledge. You can’t seek treatment if you aren’t aware that migraine is a serious neurological disease, and that treatment is available.
- Lack of referrals for headache care. Doctors could help fill that knowledge gap, but may not be giving Black patients the information and referrals they need. Studies show that African-Americans are much more likely to go to the emergency department for health visits than patients in other racial groups. In the ED, where headache is a common complaint, and where opioids are more likely to be prescribed (despite being a low-quality headache treatment and a risk factor for medication overuse headache, as well as more chronic headaches), a patient may be less likely to get an accurate diagnosis, treatment and referral for follow-up care.
- Lack of access to migraine care. Time, money and geography all present obstacles when there are only 700 headache specialists in the whole country. I’m one of them, currently located in East Lansing, Michigan, an hour and a half drive from the majority-Black city of Detroit. A patient without a car would need to take at least three buses to come see me — a four-hour trek one way.
- Distrust of the medical establishment. Historical abuses of Black patients by the medical establishment have sown a distrust of the profession. Sadly, that suspicion is reinforced whenever patients encounter bias by healthcare providers.
- Racism. Race is a social construct. Racism is a social determinant of health that may play a tremendous role in health policies and health inequities and disparities.
Black headache patients seeking care encounter bias, stereotyping and prejudice. Negative associations that we make subconsciously — called implicit bias — can unintentionally steer our behavior towards others and is one of the biases Black patients face. That includes:
- Misperceptions about Black patients and pain. Age-old false beliefs persist, many stemming from slavery, about biological differences — for example, a false belief that Black people have thicker skin or a higher pain tolerance than Whites. A 2016 study discovered that such false beliefs were endorsed by half of White medical students and residents sampled, and that those same providers rated Black patients’ pain as less severe than that of White patients, leading to less appropriate care decisions.
- Interestingly, other studies have shown that Black patients receive less pain medication than White patients even when care providers say they perceive the same levels of pain.
- Misperceptions about drug-seeking behavior. African-Americans go to the emergency room for their healthcare 54% of the time, more than any other group. But people who come to the ER for pain are also more likely to be perceived as opiate seekers, and thus viewed with skepticism. I know of one Black migraine patient who, when an attack is bad enough to warrant an ER visit, takes the time to dress up first, so that she looks “respectable” enough for her pain to be taken seriously.
Next steps toward greater equity
Disparities affect a range of communities in different ways, and learning about those impacts can feel disheartening. However, I choose to see this moment as a hopeful one. Getting our arms around a problem is the first step toward finding a solution, and the more we learn about inequities, the better positioned we will be to address them. It’s important that we continue encouraging research in this area. The American Headache Society, acknowledging that “racism is a public health issue,” has formed a Diversity, Equity and Inclusion Task force that could be helpful in deciding the priorities going forward.
If you are a person of color with migraine, I want you to know: You are not alone in your diagnosis. Relief is available. You are deserving of treatment and care. Make that doctor’s appointment. Start empowering yourself through education. Know that despite migraine, there is so much within your control, beginning with things you can do for yourself right now. You are worth it.
Author’s note: In keeping with APA guidelines for bias-free language, all names of racial and ethnic groups are capitalized.