Association of Race and Ethnicity With Emergency Room Rate of Migraine Diagnosis, Testing, and Management in Children With Headache

Danielle Kellier, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Marissa Maliakal Anto, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Matt Hall, Children's Hospital Association, Lenexa, KS.
Jennifer Marin, Departments of Pediatrics, Emergency Medicine, and Radiology, University of Pittsburgh School of Medicine, PA.
Kendall Nash, Division of Child Neurology, Departments of Neurology and Pediatrics, University of California, San Francisco, Benioff Children's Hospital San Francisco.
Elizabeth M. Wells, Center for Neuroscience and Behavioral Medicine, Children's National Hospital and the George Washington University School of Medicine and Health Sciences, DC.
Nicholas S. Abend, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Melissa L. Hutchinson, Neurology Division, Department of Pediatrics, The Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus.
Mahendranath Moharir, Division of Neurology, Department of Pediatrics, The Hospital for Sick Children and University of Toronto, Ontario, Canada.
Ricka Denise Messer, Section of Child Neurology, Department of Pediatrics, University of Colorado, Aurora.
Jamie Lee Palaganas, Division of Child Neurology, Department of Pediatrics, Weill Cornell Medicine, New York Presbyterian Hospital, NY; and.
Juan Piantino, Section of Child Neurology, Department of Pediatrics, Oregon Health & Science University, Portland.
Christina Szperka, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.
Craig Press, Perelman School of Medicine at the University of Pennsylvania, Philadelphia.

Document Type

Journal Article

Publication Date

3-11-2025

Journal

Neurology

Volume

104

Issue

5

DOI

10.1212/WNL.0000000000213351

Abstract

BACKGROUND AND OBJECTIVES: Headache evaluation and treatment are believed to be influenced by race and ethnicity. Specific headache diagnosis assigned in the pediatric emergency department (ED) may compound disparities. We sought to investigate racial and ethnic disparities in the diagnosis, testing, and treatment of pediatric patients with headache presenting to the ED. METHODS: We performed a cross-sectional analysis of ED visits from 49 children's hospitals between 2016 and 2022 from the Pediatric Health Information System, an administrative database of ED and hospitalized encounters within children's hospitals in the United States. Index encounters in the ED from patients (aged 5-21 years, median age 13 [10-15]) with a primary diagnosis of migraine, headache, new daily persistent headache, or tension-type headache were included. Encounters with trauma, infection, and malignancy where secondary headache was possible were excluded. The primary outcomes were the rates of migraine diagnosis, testing, and treatment. We used generalized estimating equations to estimate associations between race and ethnicity and outcomes after adjusting for demographic factors, medical complexity, visit timing, and final headache diagnosis. RESULTS: A total of 309,678 encounters were included while 61,677 repeat visits, 81,821 visits with diagnoses suggestive of secondary headache, and 5,714 visits from 3 hospitals with sparse data on patient race/ethnicity were excluded. Of 160,466 eligible visits (59.8% female), 41% were by non-Hispanic White (NHW) children, 24.8% non-Hispanic Black (NHB), and 26.0% Hispanic/Latino (HL). NHW children were more frequently diagnosed with migraine (45.5% vs NHB 28.2% and HL 28.3%, p < 0.001). NHB and HL children compared with NHW children received less testing including brain MRI scans (adjusted odds ratio [aOR]: NHB 0.56 [95% CI 0.46-0.69] and HL 0.54 [0.36-0.82]). There was no difference in the proportion of visits without administration of headache-related medications (NHW 23.3% vs NHB 24.6% and HL 23.4%, p = 0.64). NHB and HL children were more likely to receive only oral medications (aOR: NHB 1.37 [1.2-1.56] and HL 1.54 [1.34-1.76]) and less likely to be admitted inpatient (aOR: NHB 0.8 [0.66-0.97] and HL 0.65 [0.44-0.94]). DISCUSSION: NHB and HL children in the pediatric ED with headache receive fewer migraine diagnoses, less testing, and less intensive treatment compared with NHW children. Beyond affecting headache management, this inequity in migraine diagnosis requires further consideration to include children from marginalized racial and ethnic groups in future migraine research.

Department

Neurology

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