Eleven Reasons People Decide to Choose Headache Medicine: There may be a headache medicine provider shortage but there are ways to foster interest

Introduction

There is a huge shortage of headache specialists in the country. Only 564 United Council for Neurologic Subspecialties (UCNS) accredited headache specialists practice in the US, however the current demand is much higher, with a conservative estimate of approximately 3700 headache specialists needed to help treat only a small percentage of those affected by migraine. (1) Considering population growth, the same model predicts a need for 4500 headache specialists by the year 2040. Thus, demand for headache specialists is a major public need. A better understanding of why people choose the field of headache and ways we can leverage this understanding to promote further interest in the field is greatly needed.

Background on the Headache Provider Shortage

The shortage of headache specialists has been proposed to be due to the lack of headache education throughout the medical training pipeline. The average time devoted to headache education was only 3 hours among medical schools (2). Thus, understandably, about 68% of neurology residency program directors believe medical school graduates have insufficient knowledge in headache medicine upon entering residency (3). Only about a quarter (26%) of neurology residency programs have a mandatory headache clinic rotation (4). While 51% of neurology residency directors believe that a sufficient amount of clinic exposure to headache should be more than 4 weeks, only 12% of the programs dedicate more than 4 weeks of curriculum to headache clinic. Time spent on didactic headache education was variable; 31% reported greater than 10 hours, 42% reported 6-10 hours, and 28% reported 1-5 hours.

Examples of Efforts to Increase Exposure to Headache Medicine and Headache Medicine Training

On the residency level, the American Headache Society (AHS) sponsors a Mentoring Luncheon on Careers in Headache Medicine at the annual American Academy of Neurology meeting. This provides an opportunity for trainees to have an informal lunch with headache specialists representing various types of practice in the field (academic, private, clinical, research, education, industry). There is also the AHS Resident Education Program, the half-day Resident Education for Assessment and Care for Headache (REACH) program, and the International Headache Academy (IHA) Program. (More information about these opportunities below)

On the fellowship level, there have been significant efforts from the AHS and from individual headache specialists across the country to try to counteract the shortage of headache specialists by increasing the number of accredited headache fellowships across the country, which rose from 25 in 2014 (5) to 43 in 2020 (6). Fellowships are typically one-year long, but some programs now offer two-year fellowships to promote additional training in headache research and education. Another effort has been to ask Congress for funding to train headache specialists (7).

Sources of Inspiration for Entering Headache Medicine/Challenges Identified/Ideas for Overcoming the Challenges and How to Increase Exposure to Headache Medicine

Herein, we provide reasons why (also known as “sources of inspiration”) trainees entered the field of headache medicine, the current challenges and ways to overcome the challenges (Table 1). We invited headache fellows on the Headache journal club list (30 subscribers) to share their inspirations and challenges in the field of headache. We asked them to share, “What inspired you to pursue the field of headache medicine and what challenges you have faced. Also, what measures/changes would you propose to solve the challenges?” We stated that if they shared their ideas they would be included as collaborators on this piece. Seven fellows responded with their own personal experiences and thoughts in a general discussion format. Some highlights of the inspirations, challenges and potential solutions are as follows:

Table 1:

Eleven sources of inspiration explaining why trainees entered the field of headache medicine, the current challenges and ways to overcome the challenges

11 Sources of inspiration	Current challenges	Potential ways to overcome the challenges	Quotes from current fellows
1. High quality training in headache medicine in medical school and/or residency	Lack of adequate time and resources devoted to headache medicine in medical school and residency curriculum	Assign a greater proportion of didactics to headache topics Create OSCE and Simulation sessions to assess and improve clinical skills Utilize resources such as the AHS REACH program	“In medical school, we had headache specialists give talks during lunch conferences, which actually re-defined the field of headache medicine for me” “We had a lot of useful, practical lectures on headache during neurology clerkship” “I was amazed by the intricacies of the different diagnoses, and I was drawn to the personalized nature of the field. These feelings were only deepened by rotating in a pediatric headache clinic during residency”
2. Participation in headache medicine education programs such as the AHS Resident Education Program and the International Headache Academy program	Lack of awareness of such programs Incompatibility with curriculum	Increase awareness of such programs Encourage participation and offer guidance for application if needed Allocate travel time and funding for such programs	“…was deciding between headache or epilepsy but attending the AHS Resident Education Program really made it clear for me”
3. Attendance at headache conferences or exposure to topics on headache medicine at other neurology/medicine conferences	Lack of funding/travel allowance Lack of curriculum flexibility to allow conference attendance	Increase awareness of such conferences Allocate travel time and provide funding for the conferences	“I used funding from program to go to a 2 headache conferences and got to know many people and the newest therapeutics”
4. Exposure to headache centers and to inspiring headache disorder cases during training	Lack of exposure to headache centers and clinics Lack of exposure to long-term follow-up of “success stories” with reduction in disability and improvement in quality of life Disproportionate exposure to severe, refractory headache cases in-hospital due to more time spent on inpatient services Misdiagnosis and inadequate treatment approach at continuity clinics not staffed by headache specialists	Establish headache clinics and incorporate them into neurology clerkship or residency curriculum Increase presence of headache specialists at resident continuity clinics Allocate travel time and funding for away electives at headache centers Increase availability at headache centers to accommodate visiting students and residents	“I was fortunate to get some experience in Headache subspecialty clinic during my residency with a very friendly and encouraging fellowship trained headache attending” “I think the best experience that a trainee can have, which I was fortunate to have, is to see a patient who was really struggling to get better” “There were false beliefs that patients could not be helped and that most of them had a psychiatric etiology to their complaints. Once I got to know the headache physician at my residency institution and spent time in her clinic, my viewpoint completely changed.”
5. Support and acknowledgement from co-residents and faculty for interest in headache medicine	Propagation of stereotypes and myths regarding headache medicine as a field Lack of encouragement or sometimes understanding from faculty and co-trainees towards interest in headache medicine	Foster collaborative approach with other neurology subspecialties and clinical departments for headache education such as CME courses and procedural seminars Increase awareness of cutting-edge advances and utilization of evidence-based therapies to close the practice gap among neurologists and other clinical departments also treating headache disorders	“I had decided to do a stroke fellowship…attendings discouraged decision of mine to do an additional training in headache medicine. Sometimes even made fun of this. I also get questioned why I did these two fellowships and I have to answer it as if I have to prove that I am not crazy” “…as a syndrome even within neurology, attendings in other neurologic subspecialties don’t want to deal with headache patients… many of my attendings criticized my desire to go to into headache medicine”
6. Interest in headache medicine procedures such as nerve blocks and Botox	Lack of awareness of the multitude of procedural skills that headache medicine provides Lack of formal credentialing process Lack of formal training protocol	Offer medical students the opportunities to observe and participate in the variety of bedside procedures during neurology clerkship Work with experienced programs to establish a formal training and credentialing protocol for headache procedures for neurology residents	“I had always liked procedures in general. Headache allows me to perform many different kinds of simple, quick, bedside procedures in the office on my own. The best part is patients sometimes they feel better right away! The immediate gratification can not be overstated”
7. Research exposure and/or opportunities in headache medicine	Lack of opportunities for medical students and residents to be involved in headache research Lack of adequate funding for headache research Lack of guidance on how to design studies, collaborate, secure funding or work with industry	Increase funding for headache medicine research through advocacy initiatives Recruit more medical students and neurology residents in core roles in clinical and bench research, provide guidance and mentorship to fulfill the need for people pursuing careers in headache research	“…the opportunity to work on several research projects including functional MRI studies, systematic reviews and case studies. I became very interested in the research in headache medicine, as I realized this is an exciting field with lots of unknown questions and great potential to make a difference”
8. Mentors in headache medicine that are readily available and provide meaningful guidance	Lack of availability of mentors in headache Lack of protected time and explicit funding for mentoring activities Without proper guidance and exposure, stereotypes and bias towards headache medicine can veer medical students and residents away	Procure time and explicit funding for mentorship activities Create gatherings at neurology and headache conferences for establishing mentoring relationships for trainees without access to headache specialists at home institution Long-distance mentoring and co-mentoring can supplement traditional mentorship mechanisms to increase availability of mentorship	“Having a close relationship with a mentor is inspiring. It helps you learn so much about the field and want to get involved and contribute. It makes you feel supported. It gives you ideas. You feel part of a team.” “…having a mentor passionate about headache medicine is a huge plus and one that I was lucky to have” “For me the biggest source of inspiration was a personal mentor. I would not have gone into headache medicine if it were not for being exposed to a headache attending physician during my neurologist residency.”
9. Headache specialists in leadership positions at home institution that endorse expansion and improvement of headache education and research	Lack of involvement of headache medicine specialists in leadership positions	More active participation of headache specialists in leading the educational and departmental development efforts	“Luckily I had pioneers of headache medicine in leadership roles in my residency program and we had a lot of exposure to headache education since day one of residency”
10. Belief that a career in headache medicine can provide controllable lifestyle or adequate pay	Burn out among neurologists and headache physicians Lack of fair reimbursement/compensation Lack of flexible or scheduling or lifestyle	Education and support at various stages of training for techniques to increase documentation and procedural efficiency Early education to ensure familiarity with the physician reimbursement and RVU system Neurology departments and headache centers could allow scheduling flexibility tailored to physicians’ lifestyle and other academic commitments Headache and neurology physician organizations could campaign for higher compensation	“You have a lot of flexibility in constructing your clinic schedule…You can be more focused on procedures versus consults, or equal amounts of both” “I learned while shadowing headache specialists that efficacy is key” “I wished I learned more about the billing aspect of things as a resident”
11. Increasing demand of headache medicine physicians and good future employability	Lack of awareness of such demand Lack of fellowship positions	Bring recognition of headache medicine demand through interviews and published articles on journals and websites, as well as through increased exposure to headache clinics/centers Secure funding for more headache medicine fellowship positions through advocacy initiatives such as Headache on the Hill	“It is also great to be part of a developing field. It is an exciting time for headache disorders and treatment development. It is so wonderful to be part of this era, witness the development, and try to get involved. The fact that it is a developing field leads to more research and leadership opportunities.”

Clinical Exposure

Though less than half of headache specialists, fellows or residents interested in headache medicine reported exposure to a headache center during residency, it is among the top 3 most frequently cited reasons for gaining interested in headache (8). For programs affiliated with a headache center, requiring a rotation at the headache center during residency can provide a structured environment for the systemic clinical learning of headache medicine. However, with the limited number of headache centers that are disproportionately distributed across the country, many residents do not have exposure to headache centers at their home institutions (9). Creating scholarships to fund away-electives for motivated residents at headache centers can help overcome this limitation.

Formal Headache Education

Establishment of a formal credentialing process for headache procedures can increase awareness of the multidimensional practice of headache medicine, and might provide residents with powerful tools for effective treatment, thus potentially increasing sense of fulfillment (10). Standardizing headache knowledge by implementing formal headache medicine milestones for residents (or even earlier for medical students) through Objective Structured Clinical Examination (OSCE) sessions might also prove useful. Simulation sessions designed specifically for headache medicine topics can also be incorporated into the curriculum. Expansion of the half-day AHS REACH program and encouragement and support (financial and scheduling flexibility) for residents to attend educational conferences such as the AHS Resident Education Program can help residents obtain high-quality education and also increase the profile of headache medicine as a subspecialty. These efforts will need the endorsement of departmental leadership. There is low interest in headache medicine from neurology department chairs and residency program directors (11) which may result in less emphasis on headache education during neurology training. Increased involvement of headache medicine specialists in leadership positions of neurology residency education might be able to help counteract this trend (4).

Mentorship

Mentorship in the field of headache is the top reason to gain interest in headache medicine (8). In fact, the most pressing questions/issues considered by fellows and neurology residents are related to career planning (12), which can benefit tremendously from mentorship. Therefore, strategies to improve the availability and the quality of mentors are crucial in order to recruit and retain talented neurologists in headache medicine. Protected time and explicit funding should be made available for mentorship activities. When needed, long-distance mentoring might also be implemented. Co-mentoring and accepting multiple mentees can also help increase availability and quality of mentorship (13).

Research

Research experience in the field is also one of the top reasons for gaining interest in headache (8) and research is identified as one the most pressing issues among trainees and early career headache specialists (12). A 20-year analysis of National Institutes of Health grant funding for headache disorders noted that the estimated need for funding (>$103 million annually) far exceeds issued funding (between $6.8 and $13 million) (14). More trainees should be exposed to clinical and bench headache research to help stimulate research careers in the field.

Conclusion

We advocate for more formal headache training programs locally, regionally, and nationally as such opportunities raise awareness about our field and introduce trainees to potential mentors and research opportunities. There are many reasons to be hopeful that our field will continue to expand (15). By highlighting the sources of inspiration of what led people into the field, it will be a voice to try to deal with any challenges.