Headache Horizons: Integrating Community Health Workers Into Migraine Care

Despite advances in the field of headache medicine with new pharmacologic, neuromodulation, and biobehavioral treatment options becoming available, migraine remains underdiagnosed and undertreated, and rates of disability related to migraine have not improved. A 2007 American Migraine Prevalence and Prevention study found that only 13% of participants with migraine were using preventive treatment despite 38.8% being eligible, and that 22% had moderate or severe migraine-related disability.1 In the 2018 Observational Survey of the Epidemiology, Treatment and Care of Migraine (OVERCOME), 42.4% of participants with migraine had at least moderate disability, 51% had a migraine consultation within the past year, 22.7% were taking a triptan, and 16.8% were using migraine preventive treatment despite 40.4% being eligible.2 The High-Frequency Migraine Report Card population-based survey found preventive, acute, and over-the-counter medications were used by 15% to 16%, 28% to 37%, and 57% to 59% of participants, respectively.3 Delayed diagnosis and subsequent suboptimal migraine treatment contribute to disease progression and hence disability.4 The lack of progress in terms of diagnosis, treatment use, and disability over time demonstrates that better outcomes do not necessarily follow the introduction of novel therapies.

Closing the workforce gap in headache medicine is essential to improve the burden of disease in migraine. There are ~50 million people in the United States with migraine but only 848 United Council for Neurologic Subspecialties board-certified headache specialists.5 Not every person with migraine needs to see a headache specialist. However, based on medical necessity calculations, at least 3700 headache specialists are needed.6 Migraine can be diagnosed and treated by general neurologists and primary care providers, but there are shortages in both these specialties, especially in rural regions.7 In addition, headache and migraine education is limited in medical training.6 Workforce development and workforce expansion are necessary to reduce the burden of migraine through novel opportunities for migraine screening, identification, and disease navigation.

Augmenting the Care Team With Community Health Workers
Community health workers (CHWs), as defined by the US Bureau of Labor Statistics, are individuals who promote health within a community by:⁸

• Helping individuals adopt healthful behaviors
• Acting as liaisons or advocates for health needs by helping community residents communicate effectively with health care providers or social service agencies
• Implementing programs that promote, maintain, and improve individual and overall community health
• Delivering health-related preventive services, such as blood pressure, glaucoma, and hearing screenings
• Collecting data to help identify community health needs

A CHW is a frontline public health worker who is a trusted member of or has a close understanding of the community served.9 CHWs may be found in traditional health care settings such as hospitals, health departments, and pharmacies and are also employed at community-based organizations such as food pantries, women’s shelters, and religious institutions. CHW training varies among states, with some states requiring accreditation and other states having no formal training process. Because of the clear enhancement of patient care outcomes with the involvement of CHWs, some professional standards recommend the integration of CHWs into usual care.¹⁰

CHWs play a vital role in reaching into neighborhoods to address nonmedical drivers of health and help coordinate care. A project conducted in Missouri paired pharmacy technicians cross-trained as CHWs with community pharmacists for identification, education, testing, and referral of individuals at high risk for kidney disease.¹¹ In this project, pharmacists used their knowledge of conditions that place individuals at high risk for kidney disease to identify individuals who met these conditions and referred them to CHWs. CHWs contacted the individual, provided education, and enrolled the individual in the grant project. The CHW then arranged laboratory testing to obtain urinary albumin-creatinine ratios, made the laboratory appointment for the individual, followed up with the individual before the appointment, and in many cases, met the individual at the laboratory. The laboratory results were then reported back to the pharmacist for review, referral, or medication adjustments based on kidney function. After pharmacist review, the individual was contacted by the CHW and, depending upon the results, was supplied more education on kidney health, or the CHW forwarded the results to the individual’s primary care provider, made an appointment for the individual, and followed up with the individual after the appointment. Preliminary results indicated that upwards of 30% of identified individuals referred by CHWs had underlying undetected chronic kidney disease. The project itself, the results, the clinical outcomes, and the positive impact on health care of the participants would not have been possible without CHWs.

CHWs have been used in community pharmacies to augment care delivery from screenings to gap closure programs involving cardiovascular disease, cancers, respiratory disease, infectious disease, and other acute and chronic medical conditions.¹² A novel area on the horizon is integration in migraine care.

Optimizing Migraine Care with CHWs
Although migraine is a leading cause of disability, only 11.8% of people with migraine consult with a health care professional for headache, receive an accurate diagnosis, and receive minimally appropriate migraine treatment.¹³ Workforce expansion is necessary to close this gap in migraine care.

CHWs based in a clinic, pharmacy, or community-based organization are not a panacea to the challenges faced by people with migraine, but they offer a novel approach to optimizing care and increasing service sustainability. The community-based CHW is uniquely positioned to support accurate diagnosis through screening and referral. Consider, for example, the validated ID Migraine screening tool, which may be self-administered, has high utility in migraine screening and referral, and is underused.¹⁴ Data have shown that pharmacy-based CHWs can effectively close care gaps, including with immunizations,¹⁵ while pilot projects are evaluating the impact of pharmacy-based CHWs implementing screening tools like ID Migraine. The Missouri kidney disease program, discussed in the previous section, is a model for how CHWs may meet screening gaps in migraine.

Access to headache care is more limited in rural compared with urban settings. The proportion of headache specialists per inhabitants with headache disorders is also widely variable with some states not having any headache specialists.¹⁶ Recommendations about multidisciplinary approaches to headache care (including lifestyle changes with a regular and healthful diet, health psychology, biobehavioral therapies, complementary and integrative health, and physical therapy) further complicates care and may add to the care burden. Assistance is needed with care coordination and leveraging the available local resources. Data show that pharmacy-based CHWs are able to enhance patient–provider relationships and coordinate access to care.¹²

Once a migraine medication is prescribed, other potential barriers remain such as prior authorization constraints, step therapy management requirements, cost, lack of safe access to the pharmacy in some neighborhoods, and need for patient education. Many of these factors—especially cost—are correlated with nonmedical drivers of health. This is another area amenable to CHW interventions.¹² The Box provides a real-world case vignette illustrating how a CHW can coordinate access to poststroke therapy for an individual with financial insecurity. 

More states are incorporating new CHW billing codes into legislative mandates, creating sustainable financial models for CHW incorporation into practice. The largest driver for CHW services has been the inclusion of principal illness navigation services within the Centers for Medicare & Medicaid Services (CMS) in January 2024. These new Healthcare Common Procedure Coding System codes are for services rendered by certified or auxiliary staff, such as CHWs, under the direction of a physician or other practitioner. The Table provides a review of the services as delineated by CMS.¹⁷

CHWs integrated into headache medicine, neurology, or primary care clinics could provide principal illness navigation services such as helping coordinate access to medications and addressing nonmedical drivers of health (eg, transportation challenges, economic insecurity). These services should be billed outside the physician appointment by the CHW. These services generate additional nonphysician revenue into the practice while helping close care gaps and optimizing patient care outcomes. Three primary optimized migraine care needs—screening and diagnosis, access to qualified providers, and appropriate therapy—are all services that may be facilitated by CHWs. 

The greatest opportunity for health care benefit occurs when CHWs coordinate with other CHWs. For example, the coordination of step therapy, prior authorization paperwork, and other administrative challenges may be best suited as an interaction between a CHW in a provider’s office and a CHW in a pharmacy. Pharmacy-based CHWs can administer the ID Migraine tool and can provide prompt referral and scheduling for people with a high risk of migraine. Pharmacy-based models use principal illness navigation as the framework for sustainable models that may be replicated and delivered in partnership with other providers. 

Summary
CHWs provide services in the communities where people live. CHWs know how to navigate the social challenges in local communities as well as the medical system. Integration of CHWs in pharmacies has created new models to optimize patient care through gap closure programs, new sustainable revenue opportunities, and community outreach. To improve the burden of disease in migraine, we need to expand the workforce. Trained CHWs can help close the gap for communities with unmet migraine care needs.