Disparities in Pediatric Headache and Migraine Diagnosis and Treatment in the Emergency Department
Danielle Kellier1, Marissa Anto2, Matt Hall3, Christina Szperka2, Kendall Nash4, Melissa Hutchinson5, Elizabeth Wells6, Mahendranath Moharir7, Nicholas Abend2, Ricka Messer8, Jamie Palaganas9, Juan Piantino10, Jennifer Marin11, Craig Press2
1University of Pennsylvania, 2The Children's Hospital of Philadelphia, 3Children's Hospital Association, 4UCSF Benioff Children's Hospital, 5Nationwide Children's Hospital, 6Children's National Medical Center, 7The Hospital for Sick Children, 8Children's Hospital Colorado, 9Weill Cornell Medicine, 10Doernbecher Children's Hospital, 11UPMC Children's Hospital of Pittsburgh
Objective:
To identify racial/ethnic disparities in testing, treatment, and diagnosis of headache and migraine in the pediatric ED.
Background:
Diagnostic workup and treatment for headache or migraine in the pediatric emergency department (ED) may vary by race and ethnicity. Prior social disparities research has not explored differences in pediatric headache diagnosis in this setting which could impact care.
Design/Methods:
We identified ED visits with a primary diagnosis of headache or migraine from the Pediatric Health Information Systems database between 2016-2021, excluding diagnoses suggesting secondary headache. We compared rates of diagnosis, testing, and treatment between non-Hispanic White (NHW), non-Hispanic Black (NHB), and Hispanic/Latino (HL) children and adolescents.
Results:
Across 142,250 visits (60% female), NHW children comprised 41.1% of visits, NHB 24.2%, and HL 27.4%. Migraine was diagnosed more often in NHW (45.5%) compared to NHB (28.4%) and HL (28.5%) children; NHB (67.3%) and HL (67.5%) were disproportionately diagnosed with non-specific headache (NHW: 52.3%; p<.001). Adjusting for diagnosis, insurance, and other demographic traits, NHW children received more MRI scans (6.7% [95% CI: 4.7-9.4%] vs. NHB 4.0% [2.8-5.6%] and HL 3.7% [2.8-4.9%]; p=0.005), blood tests (25.0% [20.5-30.2%] vs. NHB 21.2% [18.4-24.3%] and HL 21.9% [19.6-24.4%]; p=.013), and intravenous medications (54.2% [50.2-58.1%] vs. NHB 44.2% [40.9-47.6%] and HL 43.7% [39.0-48.5%]; p<.001).
Conclusions:
NHW children were more likely to receive testing and intravenous medications compared to children of color during ED headache visits. Race and ethnicity appear strongly associated with diagnosis of migraine vs. unspecified headache which could point to healthcare access or diagnostic biases among other factors. This likely impacts interpretation of research centered on visits with a migraine diagnosis. Such disparities in disease management may contribute to overall undertreatment and underdiagnosis of pediatric headache, particularly for children of color. Future research should investigate the validity of using diagnostic codes to select children with migraine compared to alternative methods.