Why Racial Inequality is Still a Problem in Treatment of Migraine

Race is a social construct, but despite this clinical practice often continues to reflect outdated attitudes that race was a biologically valid way of distinguishing patients.¹ A medical textbook published as recently as 2016 was found to have problematic language and tone regarding race and ethnicity.²

Racial bias is even seen in healthcare software algorithms

These practices are compounded by health disparities, which can be defined as differences in health related to economic, social, or environmental disadvantage. Health disparities are linked to groups who may experience systematic obstacles based on a range of characteristics, including racial or ethnic group.³

Racism has historically been present in medicine, and without careful thought it can continue to have effects into the future. For example, racial bias has been seen in healthcare algorithms used in commercial software, such as one used to predict complex health needs.⁴

Migraine is the second most prevalent disease in African Americans

Migraine is a major disease for African Americans

Migraine has the second highest prevalence of any disease among African Americans (15.6%⁵), behind only hypertension⁶ (see US Office of Minority Health website for the prevalence of many diseases). Despite the burden of migraine for African Americans, many disparities exist:

• lower utilization of healthcare facilities⁷
• less accurate diagnosis of migraine⁸
• lower prescribing rates of acute medication⁷
• decreased quality of life⁸
• increased allodynia⁹
• increased symptoms of depression^10,11
• increased frequency, severity, and chronicity of migraines¹¹
• increased mistrust⁷

Misconceptions lead to inequality in care

About 50% of White medical students and residents held at least one false belief about a biological difference in Black patients.¹ Furthermore, studies of racial bias in pain found that White participants had higher thresholds for identifying pain on Black faces compared with White faces.¹² In both studies, the participants with more false beliefs or racial bias in pain perception were less accurate in their recommended treatment of the Black individuals.^1,12

Half of White medical students held false beliefs about biological differences in Black patients

But the problems go deeper than individual interactions. Only 69.4% of migraine clinical trials report ethnicity or race.¹³ Despite National Institutes of Health (NIH) policy, of all NIH-funded trials in 2015, only 13.4% reported outcomes by race or ethnicity.¹⁴

A concerning statistic is that 33.8% of Black patients with migraine were prescribed opioids as treatment – a higher proportion than Hispanic (23.3%) or White (23.4%) patients.¹⁵

Opioids are prescribed to 10% more Black patients with migraine than other racial groups

These data may indicate that Black patients with migraine receive lower-quality care. However, there have been no studies of racial bias specifically in head pain.

Why should you care?

There is a professional and ethical duty to reduce the burden of migraine fairly and equitably

Professor Charleston laid out compelling reasons why headache care providers should care about these issues. There is a professional duty to reduce the burden of migraine in the patient population as a whole, and an ethical duty to provide services fairly and equitably. Indeed, this commitment to eliminate any bias is already enshrined in the American Medical Association Code of Medical Ethics.¹⁶