An Optimist’s Look at Headache Education: A Conversation with Moises Dominguez

“[W]e should also look at ways to increase headache medicine education for other specialties that are at the forefront of seeing patients: Primary care physicians, internists, and others. There’s a large cross-disciplinary importance for headache across many fields. And with the right educational curricula, we can not only increase the number of headache specialists but also of other clinicians equipped with the skills needed to help tackle the need.” – Moises Dominguez

Moises Dominguez, MD, is an assistant professor of clinical neurology, and the director of the headache medicine fellowship program, at Weill Cornell Medicine, New York City, US. He is a champion for headache education. In a 2023 scoping review examining education initiatives in headache medicine, he and his colleagues, including his mentor Dr. Matthew Robbins, called for expanded evidence-based headache education, using more innovative methodology, to bring greater awareness of headache to specialties outside of neurology, as well as to facilitate improved diagnosis and treatment of headache disorders.

In this Migraine Science Collaborative interview, Dominguez speaks with freelance writer Kayt Sukel about the historical lack of structured headache medicine curricula in medical education, how social media and artificial intelligence can help make learning easier, and why he’s optimistic about the future of headache education. The interview has been edited for clarity and length.

What inspired you to specialize in neurology, particularly headache medicine?

Since I’ve been young, I’ve always been interested in the brain. I spent a lot of time conducting neuroscience research in college, and I knew that I wanted to be a neurologist before I got to medical school. Once I got there, I loved my neurology rotations. What I found most interesting were these intractable headache cases – when people went to the emergency department because their headaches were just too difficult to treat or they had to be admitted to the inpatient service to break their headache. It was very satisfying to help them.

Throughout my medical training, I also noticed that headache presented itself across specialties. So even when I rotated into outpatient primary care, or inpatient internal medicine, there always seemed to be someone who had a headache that needed to be treated. I appreciated that we could prescribe something to help them.

When I joined my residency program, I was very fortunate to meet Dr. Robbins, who is one of my mentors. Working with headache specialists showed me the potential of a career in headache medicine, and the impact they can have on patients, which was very compelling.

Headaches are very common, and you can help a lot of people using a holistic approach. It’s not just about medications; it’s about understanding what’s going on in the patient’s life, exploring non-medication approaches, how to improve their lifestyle, and identifying and addressing other medical contributors. The goal is to develop a treatment plan that best aligns with what the patient values. There are also other treatment modalities like devices and procedures. There is a lot of diversity in how you can help patients manage this common condition, which can present itself in different ways.

Moises Dominguez

I remember one of my mentors in medical school said that a lot of neurologists come into the field because they’ve had migraine. That was true for me as well. I distinctly recall having a visual aura as a child; I thought I was going to go blind. My mother, however, knew what was going on. She gave me some ibuprofen and encouraged me to rest. I learned that my mother, as well as her mother, also have migraine. So there is a personal connection to headache, too.

How much headache-specific education did you receive before residency?

During my neurology clerkship, I heard one lecture by a headache specialist at my medical school, Dr. Christopher Gottschalk. I thought it was fascinating, and he sold headache medicine well because he was a great teacher. But there weren’t a lot of educational opportunities specific to headache in medical school.

How did you become interested in promoting headache education for healthcare providers?

During medical school, I worked for a medical education start-up company. Part of that job entailed finding ways to teach a variety of topics in a digestible way, create medical illustrations, write good board-style questions, and respond to user comments. Figuring out how to write good questions and writing good explanations was really interesting to me. I love learning theory, and I love trying to find ways to simplify information in a way that’s digestible and resonates with the person who is trying to learn.

When I found my mentor in medical school, Dr. Jeremy Moeller, who was also interested in medical education, I created a video-based model of learning as part of my thesis, which included eight short, subspecialty neurology videos to teach medical students on their neurology clerkship. One of those videos was about headache medicine, which I worked on with both Dr. Moeller and Dr. Gottschalk. That was the beginning, and it helped me see all the innovative potential that education has. Today, I try to apply what I’ve learned across a variety of different educational projects.

You, Dr. Mia Minen, and Dr. Robbins wrote a scoping review looking at headache medicine education. What were some of the most surprising things you learned?

This review looked at the last 20 years. We learned there are few structured curricula for headache medicine. There’s limited formal, hands-on, procedural training, there’s no standardized assessment for competency, and there’s minimal interdisciplinary collaboration between different specialties. This tells us that we need a more formalized headache education pathway. We need more multidisciplinary training opportunities that are included not just in core neurology training, but in related subspecialties.

What surprised me is that there’s so little structured education for something so common and disabling. There’s a bit of a mismatch between the need and what’s being done about it.

How would you describe the educational landscape today vis-à-vis headache education, not just in neurology but across specialties?

People are recognizing the importance of learning about headache disorders. You can see that on a national scale because we now have more headache medicine fellowship programs. We are moving in the right direction because when you have more headache specialists, there are more opportunities for learning and mentorship, which can inspire more people to become headache specialists. I even see professional societies doing a great job of increasing access to headache education and resources. And then there is a lot of great advocacy and awareness coming from organizations like the American Migraine Foundation and events like Miles for Migraine.

That said, there is still room for improvement. But I think people recognize, more and more, the importance of headache education. And with increased awareness and mentorship, we will see more headache specialists produced over time.

You are very optimistic! Yet, many have sounded the alarm that there aren’t enough headache specialists in the United States right now, particularly outside of the Northeastern states. How do you respond to that?

There are about 850 board-certified headache specialists in the country. It’s not enough, but it’s still more than last year and the year before that. There are a lot of people who live with headache disorders, and, sure, we could focus on not having enough specialists. But we can also look at this as an opportunity to find strategic and innovative ways to address the need. Education plays a big role in that.

So I’d say, yes, having more headache specialists is very important. But we should also look at ways to increase headache medicine education for other specialties that are at the forefront of seeing patients: Primary care physicians, internists, and others. There’s a large cross-disciplinary importance for headache across many fields. And with the right educational curricula, we can not only increase the number of headache specialists but also of other clinicians equipped with the skills needed to help tackle the need.

Where are we in terms of providing headache education to other specialties?

That’s tough to say, but I would assume there isn’t a lot right now. But many professional societies are working to bring more structured educational content that is accessible to different types of specialists. For example, the American Headache Society provides First Contact: Headache in Primary Care.

Yet as we get more headache specialists, we’ll see more of that targeted education within institutions. Someone from primary care or obstetrics/gynecology might ask a headache specialist to give a talk explaining the basics of headache disorders so they can help manage patients until they can get into the headache clinic. There’s a big need, but we do see efforts being made to increase headache education.

So where do we go from here? How do we make sure we can provide digestible, meaningful content to a broader group of clinicians, and to patients?

To start, there’s a great opportunity to strengthen headache-related education at the medical student level, not only in the classroom, but also during relevant clinical clerkship rotations. Currently, some programs in the U.S. don’t require a neurology rotation to graduate, or they schedule it after the medical student has already made a decision on what kind of residency they’d like to pursue.

Providing interdisciplinary training for other fields that encounter headache is also important. Fellowship programs are a great opportunity for, say, someone in primary care, pain management, neuro-ophthalmology, or an ear, nose, and throat doctor to rotate with a headache medicine group. It’s a great way for people to see patients with headache, learn from headache specialists, and bring that knowledge back to their own field.

As we develop educational material, we should make sure it’s aligned with standards set by professional societies, like the American Headache Society or the American Academy of Neurology. And if thoughtfully leveraged, artificial intelligence [AI] could help shape innovative, active learning approaches. AI is poised to change the way we learn, and, if we take advantage of that, we can apply it to headache medicine so we can make learning more efficient, especially when there’s so much information clinicians have to keep up with.

Finally, we live in a social media world. I believe there’s a lot of potential there. A headache specialist could use these modalities to teach people about headache medicine and advocacy. Patients are already searching for answers on platforms like Instagram or TikTok. We can meet them where they are and provide those answers.

What are the consequences of too little headache education for physicians?

To start: Misdiagnosis. Migraine, for example, tends to affect people during the most productive years of their lives. When the diagnosis is missed, people suffer longer than they need to. Treatment may be delayed, or if started, may be suboptimal.

This can lead to negative consequences. Without appropriate treatment, people may experience painful episodes that decrease their quality of life. They may be unable to participate in family activities. They may have difficulty with social functioning. And they may overuse over-the-counter treatments, which may lead to a number of issues, such as liver and kidney problems, or stomach ulcers. And we know that without proper diagnosis and management, episodic migraine is more likely to progress to chronic migraine, which entails having 15 or more headache days a month. Those are all pretty big consequences.

Too little education also influences stigma, at multiple levels. Migraine is an invisible neurological condition. People may tell you that migraine is just a headache and to take an Excedrin and you’ll be fine. Or they may think people are saying they have a headache to avoid work or some other obligation. To have that happen is such an invalidating experience. Humans have an inherent need to be seen and understood, and when you have migraine, which is so stigmatized, you can’t achieve that. It causes more frustration and stress, and a lot of internal unease about what might be going on, and one may question if what they are experiencing is even “real.”

Has the lack of headache education hindered research progress?

It has definitely contributed to that. I think about it like this: When there’s limited headache education, fewer trainees develop interest in the field. That means there’s less interest in doing headache-related research. Fewer trainees will apply to headache fellowships, and thus fewer headache specialists will be produced who serve as mentors and lead research. We miss out on smart people who might ask new questions or have new ideas to better understand headache disorders and help develop new and even more effective ways to treat this disabling condition.

I should also mention that, unfortunately, migraine research has historically received insufficient funding despite it being amongst the most common and most debilitating neurological disorders. It makes you wonder: Does the lack of funding reflect or even reinforce migraine stigma? Is there a gap in recognizing its social and economic impact? It is interesting that certain neurological conditions, while unquestionably devastating, but less common, receive more research funding than this common condition. That is not to diminish the importance of those neurological disorders, but it does highlight an imbalance. We need to invest in headache research to not only advance care, but to also help reduce stigma and support those affected.

Is there anything you’d like to add or reiterate?

As I mentioned previously, we should take full advantage of the resources each institution has and explore ways to expand educational opportunities across specialties. For example, in our fellowship program, our headache medicine fellow rotates through other subspecialties like pain management, neuro-ophthalmology, dentistry, concussion, and interventional radiology. These kinds of cross-disciplinary rotations are encouraged by the United Council of Neurological Subspecialties, which recommends that programs offer electives in areas such as pain management, sleep medicine, and neuro-ophthalmology. There’s a significant opportunity for institutions to implement these cross-over rotations to create a richer and more integrated training experience.

Creating electives in headache medicine is also important. If an institution has a headache specialist or headache center, having trainees spend even one week observing and participating in their practice can be transformative. They can see the potential of headache medicine as a career and the kind of comprehensive treatment that is available. If we can have other providers, such as primary care physicians, internists, and so on, rotate with headache specialists, it would not only help increase education, but also have far-reaching, favorable consequences for the patients they care for with headache in the future.

Finally, whenever we embrace innovative approaches to teach about headache, whether it involves social media or AI, we have the potential to make learning more efficient and accessible. And by working with professional societies to increase awareness in our communities, we can broaden public understanding and engagement. There’s a lot of opportunity in fixing this gap in headache education – how can we streamline headache education, provide more of it, and make it more engaging? The potential is vast, and that’s what makes the future of headache education so exciting.

Kayt Sukel is a freelance writer based in Kansas.

Image credit: 123RF Stock Photo.