Simultaneous with the drive to ensure the acceptance of headache disorders as “real diseases,” the field of headache medicine has strived for recognition as a subspeciality with itself. Efforts to gain such recognition eventually came to fruition in 2005.
History of the subspecialty
One needs to enjoy one's work to do it well, and this applies to the treatment of headache. (Appenzeller O., no appointment needed; THE HEADACHE CLINIC, Headache 1971 (2))
In 1999, the American Headache Society (AHS) proclaimed as a major component of its mission: The AHS shall be the pre-eminent organization to enhance the care of patients with headache. To advance this mission, special interest sections were formed, and in 2000 the Academic Affairs Section was approved.
In 2002, the AHS was admitted to the American Association of Medical Colleges, Council of Academic Societies.
In 2003, AHS President Robert Daroff made a formal request to the Academic Affairs Section to develop headache fellowship programs with the long-term goal of achieving accreditation for training programs subsequently established. Dr. James Couch, chair of the American Academy of Neurology (AAN) Headache and Facial Pain Section, endorsed and encouraged fellowship training in headache. Simultaneous with this the AAN, American Neurological Association, Association of University Professors of Neurology, Child Neurology Society, and Professors of Child Neurology formed the United Council for Neurologic Subspecialties (UCNS) with its mandate to develop mechanisms for accreditation and credentialing of subspecialty training programs. The AHS, with its cosponsor the AAN Headache and Facial Pain Section, applied for recognition and in March 2005 our application was approved.
A new subspecialty area was born. In September 2006, the first examinations for certification in headache medicine were administered and 105 diplomates received certificates. That same year, 7 headache fellowship programs were accredited. A second exam has been given, raising the total accredited headache medicine subspecialists to approximately 165, and an additional 3 fellowship programs have been approved, making a total of 10.
Why does it matter?
In 1989, I was the first pain and headache fellow at the University of North Carolina. There was no such thing as a headache medicine fellowship. There was no such thing as a subspecialty of Headache Medicine. Now we have fellowships accredited to train future subspecialists and a process to certify them. “Why does it matter?” and “What does it mean?” have been the most frequently asked questions regarding certification and accreditation of programs.
The first question is simple to answer. Practitioners of headache medicine know the simple truth: “headache” has always been a word many associate reflexively with a suboptimal response to stress or a sign of psychological weakness. To reverse the extension of this inherent bias into medical training and practice hasnecessitated a social, political, and scientific movement fueled by consumers and advocates. When I completed my fellowship, I found myself amidst an environment of professional cynicism, both overt and unspoken, within an area of medicine that had no formal cohort of its own. That is why it matters: through certification and accredited fellowships, we are developing a professional legitimacy that previously was lacking. And only through this legitimacy that comes from parity will the subspecialty of headache medicine command the attention of educators, clinical peers, and payers. Successfully completing the process provided by the UCNS, with cosponsorship by the AHS and the AAN's Section, headache medicine was the second neurologic subspecialty to reach fruition and in fact is now the largest.
What does it mean?
This question is more complicated. As is typical of science, headache medicine had first to dispel biases, myths, and pretensions to knowledge among patients and practitioners. To assist in accomplishing this, we needed to understand how our early medical training influenced our own perceptions and career decisions.
Career choices among medical students have always been defined by the attitudes of mentors. In the training culture, residents and students expressing interest in headache medicine often received the same negative messages as clinical practitioners. Any attempt to mentor trainees interested in headache medicine typically was fated to occur in a culture involving sparse exposure, few options for didactic instruction and, most discouragingly, perceived, and too often quite real, negativism toward their area of interest.
In 2000, we identified approximately 65 individuals who reported engaging in headache medicine as a chosen subspecialty area in their academic practice. The majority was based in neurology, but family practice, dentistry, ophthalmology, pediatrics, psychology, internal medicine, and osteopathy were also represented. These spent most of their time in clinic, with less than 5 working as full-time researchers in the field. We found that the presence of an academic headache specialist did not guarantee the presence of a headache lecture as part of the medical school or residency curriculum. The presence on faculty of a full-time, designated academic headache specialist increased only slightly the likelihood of a medical school lecture existing dedicated to headache. How would future doctors learn how to manage headache patients?
Later that year, we surveyed academic headache specialists in neurology departments. We reported a minimum of 52 academic headache clinics. The practice characteristics of subspecialists appeared to be roughly midway between private practicing neurologists and all other academic neurologists. They were spending about two-thirds of their time in clinic. Why didn't they teach or do research at the same rate as their academic colleagues? Why, when department chairs agreed that migraine is a serious public health issue and an important subject to address in medical school, and were unanimous in their agreement that migraine is a valid neurologic disorder, did there exist such deficiencies in the state of headache education? It was apparent that programmatic development of the subspecialty could offer some resolution to this apparent incongruity. Subspecialty training in accredited programs and certification of individual experts was one mechanism to assist in that development, but the questions persisted: why should programs or individuals participate?
What are the potential benefits?
An institution that decides to establish an accredited headache program may use this as the starting point to cultivate the formation of a multidepartmental program or division within a medical school or large healthcare system. Training, naturally to include recruitment of residents and fellows, can yield subsequent generations of subspecialists with the capacity to develop innovative new programs of their own. Recognition of expert service and a growing body of scientific knowledge can lead to foundation and National Institutes of Health grants that in turn fuel further scientific advancement. These benefits will extend to the general public as the improved education of residents, medical students, and other healthcare providers steadily improves the existing standards of care for headache.
Only through this legitimacy that comes from parity will the subspecialty of headache medicine command the attention of educators, clinical peers, and payers.
Certification of headache subspecialists also provides less explicit benefits: recognition of accomplishment and expertise. For most of us, the process of professional certification began with MCATs and USMLE examinations, and the certification process developed for headache medicine utilized procedures similar to those employed by the ACGME and ABMS. The benefits to an institution of hiring and maintaining credentialed subspecialists, and maintaining an accredited fellowship, will include academic prestige, recognized expertise, and a higher likelihood of effective program direction (fellowship directors must be certified by the UCNS). The benefits to society will include consistency of knowledge and training, dissemination of standards of care, and a great likelihood of legitimate, and successful, negotiation with payers and healthcare delivery systems. Again, the external validation that comes from receiving recognition for hard work of providing care to patients so often cast aside by our healthcare system is a benefit not to be underestimated.
Many talented and dedicated people contributed to the effort that resulted in this “legitimization” process and that effort took tremendous exertion and perseverance. The process did not occur without provoking some concern, controversy, and consternation from members of the headache community. There were struggles, victories, and disappointments. From some sources came statements deriding the exclusivity of the enterprise, raising legitimate questions that relate to professional “turf” issues. The benefits of accreditation and certification are still being argued. Even so, most agree that the results obtained have substantially increased the potential for improving the care of our patients. And that, in the end, should remain the goal of any who seek to advance the banner of headache medicine.
Back to the future?
The future cannot be anything but favorable. This I firmly believe; the officers believe; the members believe; so it must be factual, not theoretical. (Robert E. Ryan, MD, AASH Presidential Address – 1968)
The efforts of our Society's founders resonate in our own accomplishments. The science of the last 50 years has brought us to new understandings of the pathobiology and impact of headache. Our Society has been a mighty instrument of change for the millions who suffer from a treatable disease. Legitimizing the subspecialty may have been only a matter of time but shepherding the process took leadership, skill, and dedication. Sustaining and advancing this legitimization is our next great challenge.