Starling, Amaal J.

Abstract Objectives/Background Our objectives were to characterize the geographic distribution and local availability of United Council for Neurologic Subspecialties‐certified headache specialists across US counties, hospital referral regions, and states, and to examine associations with socioeconomic deprivation, social vulnerability, and urbanicity. Headache disorders are highly prevalent and disabling, yet local availability of certified headache subspecialty care in the United States remains uneven. Although prior studies have described national and state‐level distributions of United Council for Neurologic Subspecialties‐certified headache specialists, important gaps remain in understanding county‐level availability and disparities in access. Prior state‐level summaries may mask within‐state differences in access to United Council for Neurologic Subspecialties‐certified headache specialists. Methods We conducted a cross‐sectional geospatial workforce analysis of United Council for Neurologic Subspecialties‐certified headache specialists in the United States as of January 7, 2026. Practice locations were mapped to counties, hospital referral regions, and states, and compared with general neurologist supply from the National Provider Identifier registry. Estimated population need was calculated by applying a national migraine prevalence to adult population denominators. We examined associations between specialist distribution and county‐level socioeconomic vulnerability, urbanicity, and region. Results Among 3144 US counties, 2870 (91.3%) had no United Council for Neurologic Subspecialties‐certified headache specialists, and 2085 (66.3%) had no neurologists. Headache specialists were entirely absent from counties without neurologists. Median county‐level headache specialist density was 0 per 100,000 adults, reflecting the absence of local subspecialty care in most US counties. Accounting for county adult population, neurologist density, urbanicity, and region, higher Area Deprivation Index and Social Vulnerability Index scores were associated with lower headache specialist rates. Each 10‐point increase in Area Deprivation Index was associated with lower expected headache specialist rate (adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.82–0.93), and each 0.1‐unit increase in Social Vulnerability Index was also associated with lower expected rate (adjusted incidence rate ratio = 0.94, 95% confidence interval = 0.90–0.98). Headache specialist availability relative to estimated population need varied markedly across counties, with substantial estimated local differences between migraine burden and certified subspecialty supply that were not apparent in state‐level summaries. Conclusion United Council for Neurologic Subspecialties‐certified headache specialists are unevenly distributed across the United States, with limited local availability of certified headache subspecialty care in socioeconomically disadvantaged and nonmetropolitan counties. County‐level analyses identified substantial local gaps in certified headache subspecialty availability that were not apparent in state‐level summaries.

Aim Incorporating patient-reported outcomes (PROs) into clinical practice and real-world research is essential to enable a more holistic assessment of treatment effectiveness, beyond migraine frequency alone. Given the number of calcitonin gene-related peptide (CGRP)-targeted treatments available, switching between CGRP-targeted preventive therapies is a common practice. Real-world evidence on switching to intravenous eptinezumab in adults with migraine for whom prior subcutaneous or oral CGRP-targeted preventive therapies failed is limited. The ongoing INFUSE study was designed to evaluate the real-world effectiveness of switching to eptinezumab in US clinical practice among adults with migraine for whom ≥1 prior CGRP-targeted preventive therapy had failed. Methods INFUSE, a real-world, non-interventional study evaluating the effectiveness of eptinezumab in US clinical practice, included adults with migraine for whom ≥1 prior CGRP-targeted preventive therapy had failed and who were newly initiating eptinezumab treatment. PROs were collected electronically. To provide an overall assessment of the change in migraine disease, Patient Global Impression of Change (PGIC) was utilized. Other outcomes allowed for the evaluation of novel end points, such as brain fog and participant-defined good days. Results The baseline population included 190 participants (female, 88.9%; 35–54 years of age, 53.7%). At month 6, 44.1% (95% confidence interval (CI): 35.3–53.4%) of participants reported “much/very much improved” on PGIC, and 75.7% (95% CI: 66.9–82.7%) reported any improvement. Mean good days increased by 6.3 per month at month 6 ( P < 0.001). Among participants reporting brain fog at baseline (93.7%), 55.8% (95% CI: 46.2–64.9%) reported improvement at month 6. Conclusion This research provides insights into capturing the broader migraine burden and the holistic impact of preventive treatment and highlights the potential for achieving ambitious goals. In this population for whom ≥1 prior CGRP-targeted preventive therapy had failed, switching to eptinezumab was associated with participant-reported, clinically meaningful improvements in PROs, including frequency, disability, disease status, and brain fog.