Received: 5 May 2022 | Revised: 1 July 2022 | Accepted: 21 July 2022 DOI: 10.1111/ane.13681 ORIGINAL ARTICLE Interest in and exposure to headache disorders among neurology residents in Denmark: A nationwide cross-­sectional survey Malene Glavind Holmsted Kristensen1 | Thien Phu Do1,2 | Patricia Pozo-­Rosich3,4 | Faisal Mohammad Amin1,5 1 Danish Headache Center, Department of Neurology, Rigshospitalet Glostrup, Objective: Headache disorders constitute a leading cause of disability worldwide, but Faculty of Health and Medical Sciences, there is a consistent absence of awareness and educational activities for healthcare University of Copenhagen, Copenhagen, Denmark providers across regions. Thus, we found it timely to identify potential structural chal- 2 Danish Knowledge Center on Headache lenges and factors that may affect acquisition of knowledge of headache disorders Disorders, Rigshospitalet Glostrup, Glostrup, Denmark and their management during their 4-­year residency. 3 Headache Unit, Neurology Department, Materials & Methods: We conducted a nationwide cross-­sectional survey of residents Vall d'Hebron University Hospital, in neurology in Denmark including, but not limited to, questions on interest in neu- Barcelona, Spain 4 rological subspecialties and disorders, adequacy of training in headache disorders, Headache and Neurological Pain Research Group, Vall d'Hebron Institute exposure to headache disorders during training including time spent on headache dis- of Research (VHIR), Departament de orders, exposure to specialist outpatient clinics, whether their hospital have a tertiary Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain headache clinic, training in specific procedures (anesthetic blockade, e.g., greater oc- 5 Department of Neurorehabilitation/ cipital nerve blockade, and onabotulinumtoxinA for headache), and an estimate of Traumatic Brain Injury, Rigshospitalet, University of Copenhagen, Copenhagen, proportion of cases with headache among patients managed in the last week. Denmark Results: The survey was distributed to 127 residents in Denmark between March Correspondence 2022 and April 2022. Of these, 59 (47%) completed all questions of the survey. Faisal Mohammad Amin, Danish Headache Headache disorders were the fourth most popular subspecialties among respond- Center, Department of Neurology, Rigshospitalet Glostrup, Faculty of Health ents (n = 15 [25%]) following movement disorders (n = 27 [46%]), vascular neurology and Medical Sciences, University of (n = 26 [44%]), and neuromuscular disorders (n = 25 [42%]). The mean number of Copenhagen, Copenhagen, Denmark. Email: faisal@dadlnet.dk hours spent in a course or a structured educational activity in headache disorders during residency was 12.1 h. Half of respondents (n = 27 [46%]) reported that they perceived their training in headache disorders to be inadequate. Conclusions: Even in Denmark, a country with excellent headache services, half of residents in neurology report an inadequate training despite a higher-­than-­average number of hours of structured educational activities. These findings should incentiv- ize stakeholders to make structural changes to improve education in headache disor- ders during the most fundamental years of training. KEYWORDS barrier, education, headache, medication overuse, migraine, residency, tension-­t ype headache, training This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. © 2022 The Authors. Acta Neurologica Scandinavica published by John Wiley & Sons Ltd. 568 |  wileyonlinelibrary.com/journal/ane Acta Neurol Scand. 2022;146:568–572. KRISTENSEN et al. | 569 1 | I NTRO D U C TI O N by the senior author of the original Spanish survey (P.P-­R.). The original survey consisted of 15 items; in the modified translation, we included Headache disorders constitute a leading cause of disability world- 21 items covering demographical information (year of graduation, wide.1 Regardless, there is a consistent absence of awareness and year of start of residency, region of education), interest in neurological educational activities for healthcare providers across regions.2 In subspecialties and disorders, interest in headache disorders, interest fact, the shortage of formal education of healthcare providers is con- in headache research, prior participation in headache research, and sidered one of the largest barriers to adequate care in both wealthy whether they perceived headache disorders to be underestimated. nations and low-­ and middle-­income countries.2,3 On average, only Furthermore, we inquired on adequacy of training in headache dis- 4 h are dedicated to headache disorders in undergraduate medical ed- orders, exposure to headache disorders during training including time 3 ucation and postgraduate educational activities do not fare better. spent on headache disorders, exposure to specialist outpatient clin- Denmark is considered to have one of the longest traditions ics, whether their hospital have a tertiary headache clinic, training in of headache care in the world, but even here, barriers and gaps in specific procedures (anesthetic blockade, e.g., greater occipital nerve headache education are identified among residents in neurology blockade, and onabotulinumtoxinA for headache), and an estimate of 4 with several of these being at a structural level. These challenges proportion of cases with headache among patients managed in the are most likely structural. Indeed, residents are expected to acquire last week. A full overview of questions is provided in Appendix S1. expertise about headache disorders through clinical experience and self-­study without any dedicated or formalized requirement of hours in specialist outpatient clinics,5 which allows for knowledge 2.3 | Surveys and experience gaps during fundamental training years. Deficiencies related to headache disorders during residency are generally not Training in neurology is categorized into a 1-­year introduction pro- corrected post-­graduation,6 which underlines the need for struc- gram and a 4-­year residency program (1st, 2nd, 3rd, and 4th year). tural educational activities during early training. Thus, we found it Surveys were circulated to residents in the main program to three timely to identify potential structural challenges and factors that regions in Denmark (North, South, and East). In East, one author may affect acquisition of knowledge of headache disorders and their (M.G.H.K.) distributed the questionnaire. In North and South, the management during 4-­year residency. organization Lægelig Videreuddannelse (Medical Further Education), an organization that deals with all matters relating to postgraduate educational activities, distributed the survey directly to residents in 2 | M E TH O D S neurology in their respective regions. 2.1 | Overview 2.4 | Statistical analysis We conducted a nationwide cross-­sectional survey of residents in neurology in Denmark. Conducting surveys is subject to exemp- We performed descriptive analyses of the data in Microsoft Excel, tion from processing at the National Committee on Health Research version 2103 (16.0.13901.20400)/April 13, 2021. We present data Ethics in Denmark. All methods were carried out in accordance with as frequencies, means with standard deviations (SD) or medians with the Declaration of Helsinki. We handled survey data confidentially interquartile range (IQR). and maintained anonymity of respondents throughout the study. 3 | R E S U LT S 2.2 | Questionnaire 3.1 | Study population The questionnaire was a modified translation of a Spanish survey con- ducted in 2016.7 The survey was designed by the Executive Board of The survey was distributed to 127 residents in Denmark between the Headache Study Group of the Spanish Neurological Society. Two March 2022 and April 2022. Of these, 59 (47%) completed all ques- authors (M.G.H.K. and F.M.A.) carried out the translation with support tions of the survey (Table 1); 27 (46%) were in the 1st year, 13 (22%) TA B L E 1 Respondent demographics All residents, Respondents, 1st year, 2nd year, 3rd year, 4th year, Median (IQR) time between n = 127 n = 59 (46%) n = 27 n = 13 n=8 n = 11 graduation and start of residency East 62 (49%) 37 (60%) 18 8 3 8 57 (45-­97) months North 37 (29%) 11 (30%) 4 2 3 2 68 (53-­117) months South 28 (22%) 11 (39%) 5 3 2 1 38 (35-­86) months 570 | KRISTENSEN et al. were in the 2nd year, 8 (14%) were in the 3rd year, and 11 (19%) were towards headache research, and 10 (17%) had some interest or were in the 4th year of their residency. The distribution of respondents very interested (n = 6 [10%]) in headache research. Most of respon- was 37 (60%) in Region East, 11 (30%) in Region North, and 11 (39%) dents (n = 53 [90%]) had never presented headache-­related data at in Region South. Mean time between graduation year and start of a scientific conference; likewise, most respondents (n = 53 [90%]) residency was 79.6 (±62.4) (median: 58, IQR: 43-­98) months. did not have any prior headache research publications. A minority of respondents (n = 10 [17%]) were involved in a research project related to headache. 3.2 | Interest in neurological sub-­ specializations and headache disorders 3.4 | Undervaluation of headache Respondents were mostly interested in movement disorders (n = 27 [46%]), vascular neurology (n = 26 [44%]), and neuromuscular disor- Half of respondents (n = 28 [48%]) reported that they believed the ders (n = 25 [42%]) (Table 2). Headache disorders were the fourth field of headache disorders to be undervalued (not valued or appre- most popular sub-­specialization among respondents (n = 15 [25%]). ciated highly enough). The overall interest was consistent across year of residency (Table 2). The number of respondents interested in headache disorders was 9 (24%) of those in Region East, 2 (18%) of those in Region North, and 3.5 | Training in headache disorders and exposure 4 (36%) of those in Region South. to patients Of the 15 respondents who reported an interest in headache dis- orders, the primary reasons for interest were the prevalence (n = 11 The mean number of hours spent in a course or a structured edu- [73%]) and treatment options (n = 11 [73%]) followed by research cational activity in headache disorders during residency was 12.1 (n = 8 [53%]) and diagnosis (n = 8 [53%]). No residents chose the (±12.9) h (median: 8, IQR: 5-­16). option “Other reasons.” Half of respondents (n = 27 [46%]) reported that they per- ceived their training in headache disorders to be inadequate. The remaining respondents (n = 32 [54%]) considered their training in 3.3 | Perception of and participation in headache disorders to be adequate; reasons reported, 7 (22%) be- headache research cause they had participated in the mandatory course in headache disorders in the main residency program, 15 (47%) because there Two-­thirds of respondents (n = 35 [59%]) believed that a sufficient is a headache unit at their training hospital, and 10 (31%) due to amount of headache research is being conducted, n = 10 (17%) re- self-­e ducation. ported that not enough headache research is being conducted, Two-­thirds of respondents (n = 39 [66%]) were currently enrolled and n = 14 (24%) reported too much headache research is being in a program at a hospital with specialized headache units or out- conducted. patient clinics. One-­third reported (n = 22 [37%]) that a rotation in Half of respondents had no (n = 18 [31%]) or only very little in- headache units/clinics was mandatory during their stay, 8 (14%) re- terest (n = 12 [20%]) in headache research, 13 (22%) were indifferent ported there was an elective option for a clinical rotation, and half TA B L E 2 Respondents in neurological All respondents 1st year 2nd year 3rd year 4th year subspecialties (n = 59) (n = 27) (n = 13) (n = 8) (n = 11) Movement disorders 27 (46%) 15 (56%) 5 (39%) 4 (50%) 3 (27%) Vascular neurology 26 (44%) 11 (41%) 8 (62%) 2 (25%) 5 (46%) Dementia 11 (19%) 4 (15%) 3 (23%) 1 (13%) 3 (27%) Multiple sclerosis 9 (15%) 5 (19%) 3 (23%) 1 (13%) 0 Headache 15 (25%) 8 (30%) 6 (46%) 0 1 (9%) Epilepsy 12 (20%) 5 (19%) 2 (15%) 3 (38%) 2 (18%) Peripheral nerve 9 (15%) 2 (7%) 3 (23%) 2 (25%) 2 (18%) disorders Neuromuscular 25 (42%) 10 (37%) 5 (39%) 6 (75%) 4 (36%) disorders Other 8 (14%) 3 (11%) 0 3 (38%) 2 (18%) Undecided 2 (3%) 1 (4%) 0 0 1 (9%) Note: An overview of number and proportion of respondents who found specific subspecialties interesting. KRISTENSEN et al. | 571 (n = 29 [49%]) reported there was no designated rotational scheme their training. For those respondents who reported adequate train- involving these units/clinics. Of those respondents who did not have ing, in most cases, it was either because they had attended the only an elective option or mandatory stay, 8 (14%) had tried to actively mandatory course in headache disorders during residency or because request hours in these units/clinics. there was a headache unit in their training hospital. This emphasizes One-­third of respondents (n = 22 [37%]) did not have the option that exposure to headache disorders is important. Interestingly, im- to be trained in anesthetic blocks or onabotulinumtoxinA injections plementation of a mandatory rotation in a specialized outpatient for headache treatment, one-­fourth (n = 16 [27%]) had the option headache clinic has previously been shown to improve deficien- to be trained in both procedures, four (6.8%) had the option to be cies.12,13 While one-­third of respondents reported that such a rota- trained in only onabotulinumtoxinA injections, none reported that tion was mandatory at their training hospital, these findings should they had the option to be trained in only anesthetic blocks, and one-­ incentivize a rotation in a headache unit to be a mandatory part of all fourth (n = 16 [27%]) reported that they did not know whether their residency programs in neurology. Assumingly, such an intervention department offered training in either options. would improve the overall knowledge of headache disorders which The mean number of consultations for headache were 5.3 (±6.3) would benefit patients and improve clinical care. This is especially (median: 4, IQR: 1-­7) visits in the past 7 days prior to inquiry and con- important considering emerging disease-­specific treatments, which stituted a mean proportion of 15.4% (±17.7) (median: 10, IQR: 5-­20) requires appropriate diagnosis and adequate follow-­up. of all consultations. 5 | S TR E N G TH S A N D LI M ITATI O N S 4 | DISCUSSION About half of potential respondents accepted the invitation and In this nationwide cross-­sectional survey of neurology residents in completed the survey; this sampling method most likely introduced Denmark, half of respondents reported that they found their train- a selection bias towards residents who were more interested in ing in headache disorders inadequate. The European Union of Medical headache disorders, and presumably, most likely to report a higher Specialists recommended that trainees should be confident in and knowledge level. In turn, this means the knowledge level among the able to make a complete diagnosis and optimize treatment within the general population of residents in neurology is more likely lower 8 first 2 years of training, yet this does not appear to be the case here. than in our sample. The number of hours of structural educational Unfortunately, these findings are not unique.9 activities related to headache through the course of a residency in There is a limited number of training hours during residency, neurology may be underestimated due to our sampling method; sev- which emphasizes the need for a structured educational program. eral respondents were not in the last part of their residency and may Our findings are despite an average of ~12 h spent on structured first participate in these activities at a later stage. training in headache disorders, which is higher than the interna- tional average. 3 This suggests that the time spent on structural educational activities for headache disorders should be higher—­ 6 | CO N C LU S I O N S perhaps much higher—­t han what is the national and international norm. While this cannot be concluded on the basis of our data, Even in Denmark, a country with a tradition and history of excel- the overall lack of interest in headache disorders (only one-­fourth lent headache services, half of residents in neurology report lack of found headache disorders interesting) and lack of participation knowledge, an inadequate training despite a higher-­than-­average in headache research activities may contribute to these findings. number of hours of structured educational activities, and a latent in- Surveys conducted in other parts of Scandinavia and Europe re- terest in this neurological subspeciality. These findings should incen- port similar findings, which suggests that an overall lack of inter- tivize stakeholders to make structural changes to improve education est in headache disorders is not an isolated Danish phenomenon, in headache disorders during the most fundamental years of training 7,10,11 but extends to other regions. Of note, while the Danish to improve clinical care. Headache Center (a global leading institute in the field) is located in Region East, the proportion of respondents with an interest in AC K N OW L E D G M E N T S headache disorders appeared to be similar here compared with None. other regions. The finding that half of respondents reported their training in C O N FL I C T O F I N T E R E S T headache disorders to be inadequate is in line with reports from de- Malene Glavind Holmsted Kristensen reports no conflicts of inter- partmental chairs. Two-­thirds of neurology chairs and resident direc- est. Thien Phu Do reports no conflicts of interest. Patricia Pozo-­ tors in a survey conducted in the United States reported that they Rosich has received honoraria as a consultant and speaker for found headache education inadequate or did not have an opinion.9 AbbVie, Amgen, Biohaven, Chiesi, Eli Lilly, Lundbeck, Medscape, As such, the perception of inadequacy is not only abundant among Novartis, and Teva. Her research group has received research residents, but also an opinion shared among those responsible for grants from AbbVie, Novartis, Teva, AGAUR, FEDER RIS3CAT, 572 | KRISTENSEN et al. la Caixa Foundation, Migraine Research Foundation, Instituto 5. Sundhedsstyrelsen and Neurologisk Selskab. Målbeskrivelse for Investigación Carlos III, EraNet Neuron, International Headache speciallægeuddannelsen i Neurologi. 2015. https://neuro.dk/ wordp​r ess/wp-­c onte​n t/uploa​d s/2012/09/60306​c f29c​7 3999​ Society, MICINN, PERIS; and has received funding for clinical tri- 672cd​e2cb6​8f17e​3f.pdf als from Alder, Biohaven, Electrocore, Eli Lilly, Lundbeck, Novartis, 6. Sobocki P, Lekander I, Berwick S, Olesen J, Jönsson B. Resource and Teva. She is the Honorary Secretary of the Executive Board of allocation to brain research in Europe (RABRE). Eur J Neurosci. the International Headache Society. She is in the editorial board of 2006;24:2691-­2693. 7. Gago-­Veiga AB, Santos-­L asaosa S, Viguera Romero J, Pozo-­ Revista de Neurologia. She is an associate editor for Cephalalgia, Rosich P. ¿Se interesan los residentes de Neurología en la cefalea? Frontiers of Neurology, Headache, Neurologia and a scientific advi- Neurologia. 2018;33:1-­7. sor of The Journal of Headache and Pain. She is a member of the 8. European Union of Medical Specialists. European Training Clinical Trials Guidelines Committee of the International Headache Requirements for Neurology. https://www.uems.eu/__data/asset​ s/pdf_file/0008/30689/​Europ​e an-­Train​ing-­Requi​remen​t s-­N euro​ Society. She has edited the Guidelines for the Diagnosis and logy-­Oct-­16-­chang​es-­marke​d-­in-­red.pdf Treatment of Headache of the Spanish Neurological Society. She 9. Kommineni M, Finkel AG. Teaching headache in America: sur- was the Coordinator of the Headache Study Group of the Spanish vey of neurology chairs and residency directors. Headache. Neurological Society from 2014–­2018. She is the founder of www. 2005;45:862-­865. 10. Zis P, Macerollo A, Sauerbier A, Papp V, Klingelhoefer L, Cock HR. midol​ordec​abeza.org. PPR does not own stocks from any pharma- Subspecialty preferences among neurologists of the future. Eur J ceutical company. Faisal Mohammad Amin has received honoraria Neurol. 2018;25:597-­601. and personal fees from Teva, Lundbeck, Novartis, Eli Lilly for lectur- 11. Kristoffersen ES, Winsvold BS, Faiz KW. Prestige of neurological ing or participating in advisory boards. disorders among future neurologists in Norway. Acta Neurol Scand. 2019;139:555-­558. 12. Zhang N, Cowan RP. On making a headache medicine rotation man- DATA AVA I L A B I L I T Y S TAT E M E N T datory in neurology training. Headache. 2019;59:1841-­1845. The data that support the findings of this study are available on re- 13. Todd C, Pavalaghanthan H, Lay C, Lagman-­Bartolome AM. Trainee quest from the corresponding author. The data are not publicly avail- headache education and management enhancement (THEME) able due to privacy or ethical restrictions. study. Can J Neurol Sci. 2022:1-­4. doi:10.1017/cjn.2022.38. Epub ahead of print. ORCID Malene Glavind Holmsted Kristensen https://orcid. 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