A Critical Exploration of Migraine as a Health Disparity: the Imperative of an Equity-Oriented, Intersectional Approach
- 36 Downloads
Purpose of Review
Despite recognition of rising prevalence and significant burden, migraine remains underestimated, underdiagnosed, and undertreated. This is especially true among groups who have been historically, socially, and economically marginalized such as communities of color, women, people experiencing poverty, people with lower levels of education, and people who hold more than one of these marginalized identities. While there is growing public and professional interest in disparities in migraine prevalence, there is a paucity of research focusing on racial/ethnic and socioeconomic disparities, and the social and structural determinants of health and equity that perpetuate these disparities. From a health equity perspective, migraine research and treatment require an examination not only of biological and behavioral factors, but of these identities and underlying, intersecting social and structural determinants of health.
Significant disparities in migraine incidence, prevalence, migraine-related pain and disability, access to care, and quality of care persist among marginalized and underserved groups: African Americans, Hispanics, people experiencing poverty, un- or under-employment, the un- and under-insured, people who have been exposed to stressful and traumatic events across the lifespan, and people experiencing multiple, overlapping marginalized identities. These same groups are largely underrepresented in migraine research, despite bearing disproportionate burden. Current approaches to understanding health disparities in migraine largely assume an essentializing approach, i.e., documenting differences between single identity groups—e.g., race or income or education level—rather than considering the mechanisms of disparities: the social and structural determinants of health.
While disparities in migraine are becoming more widely acknowledged, we assert that migraine is more aptly understood as a health equity issue, that is, a condition in which many of the health disparities are avoidable. It is important in research and clinical practice to consider perspectives that incorporate a cultural understanding of racial, ethnic, and socioeconomic identity within and across all levels of society. Incorporating perspectives of intersectionality provides a strong foundation for understanding the role of these complex combination of factors on migraine pain and treatment. We urge the adoption of intersectional and systems perspectives in research, clinical practice, and policy to examine (1) interplay of race, gender, and social location as key factors in understanding, diagnosing, and treating migraine, and (2) the complex configurations of social and structural determinants of health that interact to produce health inequities in migraine care. An intentional research and clinical focus on these factors stands to improve how migraine is identified, documented, and treated among marginalized populations.
KeywordsMigraine Health equity Health disparity Intersectionality
The authors gratefully acknowledge Dr. Shawn Kneipp, Dr. Kristen Hassmiller Lich, Dr. Janet Bettger, and Dr. Janice Humphreys for their thoughtful and insightful contributions to the development of concepts in this manuscript.
Compliance with Ethics Guidelines
Conflict of Interest
Deanna R. Befus, Megan Bennett Irby, Remy R. Coeytaux, and Donald B Penzien declare no conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance
- 2.Levy B, Sidel V. The nature of social injustice and its impact on public health. In: Levy B, Sidel V, editors. Social Injustice and Public Health. New York: Oxford; 2013. p. 3–20.Google Scholar
- 4.Raphael D. The importance of tackling health inequalities. In: Raphael D, editor. Tackling Health Inequalities: Lessons from International Experiences. Toronto: Canadian Scholars’ Press; 2012. p. 1–32.Google Scholar
- 5.United States Department of Health and Human Services. Health Equity and Disparities. 2011; Available from: http://www.minorityhealth.hhs.gov/npa/templates/browse.aspx?lvl=1&lvlid=34.
- 6.American Public Health Association. Health equity. 2015; Available from: https://www.apha.org/topics-and-issues/health-equity.
- 8.World Health Organization. Metrics: disability-adjusted life year. 2015; Available from: http://www.who.int/healthinfo/global_burden_disease/metrics_daly/en/.
- 11.World Health Organization, Atlas of headache disorders and resources in the world 2011. 2011.Google Scholar
- 16.• Charleston L IV, et al. Migraine care challenges and strategies in US uninsured and underinsured adults: a narrative review, part 1. Headache. 2018;58(4):506–11 This excellent review presents migraine health disparities within the context of social and structural determinants of health. CrossRefGoogle Scholar
- 18.Crenshaw, K., Demarginalizing the intersection of race and sex: a Black feminist critique of antidiscrimination doctrine, Fem Theory, and antiracist politics , in Feminist legal theory. 2018, Routledge. p. 57–80.Google Scholar
- 19.Dill, B.T. and M.B. Zinn, Theorizing difference from multiracial feminism, in race, gender and class. 2016, Routledge. P. 76–82.Google Scholar
- 22.• Kempner J. Not tonight: migraine and the politics of gender and health. Chicago: University of Chicago Press; 2014. This thoroughly-researched book is a very good exemplar for examining the multidimensional, intersecting social, medical, and structural processes that construct and perpetuate cultural assumptions and understanding of migraine, and how those assumptions beget inequitable outcomes. CrossRefGoogle Scholar
- 23.Chronic Pain Research Alliance, Chronic pain in women: neglect, dismissal, and discrimination. 2010.Google Scholar
- 41.National Institutes of Health. Estimates of funding for various research, condition, and disease category (RCDC). 2016 [cited 2017 May 11]; Available from: https://report.nih.gov/categorical_spending.aspx.
- 42.National Institute of Mental Health. US Leading Categories of Disease/Disorders. 2013 [cited 2017 May 11]; Available from: https://www.nimh.nih.gov/health/statistics/disability/us-leading-categories-of-diseases-disorders.shtml.
- 53.Delgado R. Rodrigo’s reconsideration: intersectionality and the future of critical race theory. Iowa Law Review. 2011;96(4):1247–88.Google Scholar
- 54.Matsuda MJ, et al. Words that wound. Westview: Boulder, CO; 1993.Google Scholar
- 56.Ladson-Billings, G., & Donnor, J. K. , Waiting for the call: the moral activist role of critical race theory scholarship., in Handbook of Critical and Indigenous Methodologies, N. Denzin, Lincoln, Y., & Smith, L.T., Editor. 2008, Sage. p. 61–84.Google Scholar
- 63.SAMSHA-HRSA for Integrated Health Solutions. Trauma. n.d. [cited 2017 December 4]; Available from: https://www.integration.samhsa.gov/clinical-practice/trauma.
- 64.•• Browne AJ, et al. EQUIP healthcare: an overview of a multi-component intervention to enhance equity-oriented care in primary health care settings. Int J Equity Health. 2015;14(1):152 Comprehensive overview of an equity-oriented approach to care, including training on and incorporating trauma- and violence-informed care and the social determinants of health, applicable to diverse practice environments. CrossRefGoogle Scholar
- 67.Substance Abuse and Mental Health Services Administration. Trauma-informed approach and trauma-specific interventions. 2015 [cited 2018 April 25]; Available from: https://www.samhsa.gov/nctic/trauma-interventions.
- 68.EQUIP Health Care. Trauma-and-violence-informed care (TVIC): a tool for health and social service organizations and providers. 2017 [cited 2018; Available from: http://www.equiphealthcare.ca/.
- 70.EQUIP Health Care. Top 10 things your clinic, practice, or department can do to create a welcoming environment. 2017 [cited 2018; Available from: Retrieved from http://www.equiphealthcare.ca/.
- 72.National Association of Community Health Centers. PRAPARE. 2018 [cited 2018 April 25]; Available from: http://www.nachc.org/research-and-data/prapare/.
- 74.Campbell, J., Penzien, D., Wall, E. , Evidence based guidelines for migraine headaches: behavioral and physical treatments. . 2000, US Headache Consortium.Google Scholar
- 77.Smitherman TA, et al. In: Wedding LBD, Freedland K, Sobell L, Wolfe D, editors. Headache. Advances in psychotherapy: evidence-based practice. Boston: Hogrefe; 2015.Google Scholar