HEADucation Initiative

Allison Verhaak

Allison Verhaak, PhD
Clinical Health Psychologist
Hartford Healthcare Headache Center
Ayer Neuroscience Institute
Assistant Professor of Neurology
University of Connecticut School of Medicine

Brian MD

Brian Grosberg, MD, FAHS
Director, Hartford Healthcare Headache Center
Program Director, Headache and Facial Pain Fellowship
Director, HEADucation
Ayer Neuroscience Institute
Professor of Neurology
University of Connecticut School of Medicine

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Headache disorders, including migraine, cluster headache, and tension-type headache, are a leading cause of disability around the world, and migraine affects 12% of the population in the United States. Migraine is often managed within the primary care setting, with migraine visits accounting for 5 to 9 million primary care visits per year. However, research suggests suboptimal care within this setting, including inaccurate diagnoses, inadequate use of preventive and acute medications, and lack of referrals for non-pharmacological, evidence-based treatments for migraine. This is likely due, in part, to a paucity of headache education in medical training programs. It is estimated that medical students have only one hour of preclinical and two hours of clinical teaching related to headache medicine. Even in neurology residency programs, research studies suggest that many department chairs and residency directors feel that headache diagnosis and management is not adequately taught in residency, and in a survey of neurology programs, only one-quarter reported having a mandatory headache clinic as part of the training program. Beyond residency, those specializing in headache medicine are far outnumbered by patients with migraine, with an estimated 700 certified headache specialists in the United States to treat nearly 40 million persons with migraine.

I am a clinical health psychologist at the Hartford Healthcare Ayer Neuroscience Institute Headache Center in West Hartford, CT, where I focus on behavioral medicine approaches to migraine management. I work with a multidisciplinary team of providers who specialize in various aspects of headache management, including physicians, physician assistants, advanced practice nurses, physical therapists, and women’s healthcare providers. At our Headache Center, my colleagues and I recognized the knowledge gaps in headache treatment across different settings, including primary care and neurology, and decided to see if we could contribute to a solution that may improve headache education in residency programs, and ultimately increase the number of practitioners available to treat patients in need.

The Hartford Healthcare Headache Center has created a novel headache medicine curriculum, termed “HEADucation”, that is an online, case-based, live and interactive lecture series for primary care internal medicine residents and neurology residents. Beginning summer and fall 2021, we will pilot this program for primary care with the University of Connecticut Primary Care Internal Medicine residents, and will also pilot a separate curriculum for neurology residents with the University of Connecticut, University of Massachusetts, and Brown University. It will be moderated by Hartford Healthcare Headache Center specialists and will cover the practical care of patients impacted by headache. HEADucation will implement a pre-test assessment of residents’ baseline knowledge of headache and a post-test assessment which will provide insight to the efficacy of the curriculum.

Topics will include:
• Best practice recommendations for taking a thorough headache history
• Review of examination of the patient with a primary complaint of headache
• Identifying red flag signs and symptoms before a headache diagnosis
• Evaluating for secondary headache disorders
• Diagnosing migraine and other primary headache disorders
• Understanding risk factors for headache chronification, including medication overuse headache
• Case-based discussion of acute and preventive treatments
• Non-pharmacological approaches to migraine management
One of my roles in the HEADucation initiative will be to provide pertinent education related to level A, evidence-based, behavioral interventions for migraine management, including cognitive behavioral therapy, biofeedback, and relaxation skills training. Just as important, we will be covering how to speak with patients about behavioral health referrals for non-pharmacological treatment for migraine, as well as how to identify potential providers in the community that may be trained in these treatments. In some cases, patients with migraine may interpret a behavioral health referral as a provider believing that the pain isn’t real, or that stress is causing their pain. Instead, it is very important for providers to explain that behavioral treatments are a necessary, evidence-based part of migraine management, and treatment outcomes are often optimized with a combination of pharmacological and behavioral approaches. In my clinic, I work with patients with migraine to address many different concerns that may negatively impact headache patterns, including stress management, mood and anxiety disorders, sleep disturbance, and lifestyle factors (caffeine use; hydration; consistent eating patterns).

We are excited to pilot our HEADucation program over the next year, and hope to publish findings related to the implementation and efficacy of the program. In addition, we hope to learn from this pilot year, with the intention of further developing the program to be offered to an expanding geographic region to other residency programs in years to come.

Acknowledgement: HEADucation is funded by educational grants from AbbVie, Amgen, and Theranica.

References:

Ahmed, Z.A. and Faulkner, L.R. (2016), Headache Education in Adult Neurology Residency: A Survey of Program Directors and Chief Residents. Headache: The Journal of Head and Face Pain, 56: 871-877. doi:10.1111/head.12822

Gibbs TS, Fleischer AB Jr, Feldman SR, Sam MC, O’Donovan CA. Healthcare utilization in patients with migraine: demographics and patterns of care in the ambulatory setting. Headache. 2003;43:330-335.

Migraine Research Foundation: Migraine Facts (https://migraineresearchfoundation.org/about-migraine/migraine-facts/)

Minen MT, Loder E, Tishler L, Silbersweig D. Migraine diagnosis and treatment: a knowledge and needs assessment among primary care providers. Cephalalgia. 2016;36:358-370.

Verhaak AMS, Williamson A, Johnson A, Murphy A, Saidel M, Chua AL, Minen M, Grosberg BM. Migraine diagnosis and treatment: A knowledge and needs assessment of women’s healthcare providers. Headache. 2021 Jan;61(1):69-79. doi: 10.1111/head.14027.