Dear Doctor: Audrey Halpern
The neurologist and headache medicine specialist at Manhattan Center for Headache & Neurology on finding the right treatments for her patients and battling the gender inequality in neurology.
Though over 45 million people in the US suffer from acute or chronic headaches, data shows that the condition is still undertreated and underdiagnosed. Dr. Halpern believes that better educating future neurologists and headache specialists is the first step to helping patients receive effective care. The second step? More advancements in treatment. Read on to learn about how she believes the medical community can embrace headache as a condition and make crucial steps to balancing the gender inequality experienced by patients and physicians alike.
How did you get started in medicine and what inspired you to choose your specialty?
Like many physicians, I wanted to be a doctor from as early as I could say the word. I was very young when I felt the calling, due in part to the formative memories I had of my grandfather getting sick. I knew I wanted to take care of him and help him, and soon realized that I wanted to do that for other people, too.
But it wasn’t until my first semester in medical school that I fell in love with neurology and neuroanatomy. Specifically, I remember participating in a small group learning session of what we call “localizing the lesion.” You had to use symptoms and findings to try to figure out where a lesion in the nervous system was based. As with much of neurology, it was like an intellectual puzzle of the unknown, and I fell for the process.
I soon realized that my cerebral nature lent itself well to neurology. Around this time, there weren’t a lot of treatments for neurological conditions. The neurologist was the specialist that all of the other doctors called for a consultation when nobody could figure out what was going on with a patient. But there also wasn’t a lot of long-term care in neurology.
By the time I began my training, more advancements in treatment emerged for conditions like stroke and migraine. Suddenly, there was a reason to go beyond puzzle-solving and actually develop relationships with patients with chronic conditions. This was the combination that really called to me during my development as a physician and neurologist.
Soon, I found my way into headache medicine, which maintained the allure of the unknown. When I started, we knew very little about headache, though we know so much more now, which is both amazing and exciting.
The last piece that fell into place for me was developing relationships with women. Migraine predominantly affects women, and I really like taking care of women. All in all, I feel very fortunate to have found the absolute perfect specialty for me.
What makes your treatment of migraine and headache different?
One of the things that most of us learn in medical school is that 90% of a diagnosis is in a patient’s history. In headache medicine, this rings especially true.
I often do patient histories that take two hours, and I do it lovingly, because I enjoy the details and know how important they can be. I revel in the fine details and extensive histories because they help me to find the best combination of treatments for that patient.
Why is it important to find the right combination of treatments, rather than just a single treatment?
Every single patient is different and every single patient’s experience of migraine is different. There are no two people with the same migraine experience.
Any headache specialist can prescribe Ubrelvy or Botox, but it’s finding the right combination of treatments for that patient that really makes the difference. In order to do that, I need to go a little above and beyond, even in our follow-up appointments. Even when you find the right treatment or treatment combination for your patient, it’s still an ongoing process. A patient may return to say “The treatments are generally working, but I’ve had this horrible migraine for the last week,” or “Now that I’m pregnant, what can I do to treat my migraines?”
The human body is a changing landscape that continuously feeds into the headache condition. To be an effective headache medicine specialist, I have to be flexible and attentive.
Headaches are the number two cause of disability in the U.S., yet they are consistently underdiagnosed. What can the medical community do to better embrace headache as a medical condition and accurately diagnose those who suffer?
Things have improved in recent years, but there’s still a lot to be done. First, there’s a significant lapse in education. Headache disorders are not adequately focused on in medical school or residency — even neurology residencies.
In fact, the ACGME just updated their neurology requirements list to include headache disorders. The ACGME is responsible for accrediting residency training programs and generates the list of conditions and disorders that every neurology residency should teach and that a student completing a neurology residency should be efficient in diagnosing and treating. Until this summer, headache disorders weren’t even on their list.
The second area where there’s still room for improvement is treatment. Therapeutics have actually come a long way since I started in that there are more physicians interested in treating headache now. Having good therapeutics creates an interest in treating the disorder, which then creates an interest in learning how to diagnose it.
At a recent virtual event, you led a conversation on “Leading Women in Medicine.” Can you tell us more about your experience with gender inequality in medicine, and specifically, neurology?
There are two areas of gender equality in neurology: treatment and practice. When it comes to the treatment of headache, the condition has often been ignored because it predominantly affects women. Decades ago, the condition was actually considered a “hysterical problem,” before that term rightly fell out of favor. Women may also present differently with headache or other neurological conditions. In addition, a woman’s menstrual and hormonal cycles can affect neurological conditions greatly, but not every specialist will be attuned to these factors.
Then there’s the other side, which is the gender inequality in careers for women in neurology. I’m hopeful that I’ve experienced less discrimination and harassment than my predecessors, and even more hopeful that the women training today will experience much less.
That being said, when I was a medical student, my university did not have a lot of female surgeons. In fact, there was only one full-time female surgeon on faculty at the time. Though I had always been interested in the idea of neurosurgery, the department where I studied did not have any women, so I didn’t exactly think it was doable.
Then, when I was a senior, they admitted their first woman to the neurosurgery program, and it was a big deal. The news spread that the university had only accepted this woman because her husband was coming into the program too, and they weren’t happy about having her in the department. So I didn’t even consider following in her footsteps.
When I arrived at Yale for my neurology residency, by contrast, half of the neurosurgery residents were women. I was awestruck. My experience shows how we make — or don’t make — major life decisions based on the examples that we see or don’t see in the world. Again, we see positive changes in this regard with women like Kamala Harris being nominated for the vice presidency and more and more women entering neurology and neurosurgery programs. Representation expands the realm of possibilities. We need women in these examples to be uplifted, so that women who come after us believe that it’s possible.
In addition to representation, what steps can the medical industry take to better balance this inequality?
I think it’s going to be very difficult. It’s going to take some strong leadership from men in positions of power in medicine who go out of their way to make sure that women are being given the same opportunities and pay.
We need leaders to say: “We want women here.” We need leaders to put these women up front and give them grants and promotions so that younger women coming up in their fields have examples of an equitable standard in their industry.
I think one of the potential inroads to this is by talking about the inequalities in the care of our female patients. A lot of men are interested in treating women and women’s health. They’re interested in MS, headache medicine, and treating conditions that affect so many female patients. As good doctors, they’re interested in being good caretakers. I hope that by learning about the inequalities that their female patients face, it will help to advance the vocabulary around the inequality and the acceptance that these differences are real.
How do you see your practice, and medicine in general, shifting to accommodate a post-Covid-19 world?
I strongly believe that telehealth is here to stay. I can’t imagine patients being okay with never having telemedicine again — it really makes going to the doctor and taking care of yourself so much more convenient. Of course, there are certain things we cannot do virtually, but now that people have experienced virtual care and trust it, I think it will be an important part of our permanent medical landscape.
In more general terms, I think we’re going to have to adjust our sensitivity to things like wearing masks, gloves, or staying home while sick. We can’t return to the nonchalant ways of before Covid. In places like New York City, I think we will continue to see people wearing face masks on the subway or in doctors’ offices even after the worst of the pandemic is over — similar to what many people already do in many densely populated cities in Asia.
This may turn out to be the dawning age of normalizing personal protective equipment, especially if these kinds of outbreaks become more frequent. Will social handshaking, kissing, and hugging become a thing of the past? It’s hard to tell, since we are very touchy here in the US. But it will be interesting to see.
Vital Signs
Best meal you’ve had to-go recently? The pulled chicken sandwich from Poulet Sans Tete. It’s served on a toasted garlic baguette with a rich natural jus — it’s absolutely delicious.
Go-to tip to soothe a mild headache? Deep breathing and peppermint tea.
What’s your favorite place in New York for a walk? Battery Park.
Do you have a secret talent? If I told you, it wouldn’t be secret.
If you weren’t a doctor what would you be? An astrophysicist. I love space science and particle physics.
What’s one healthful habit you’d love to see patients adopt? Good sleep hygiene. This means going to sleep at the same time every night and waking up at the same time in the morning. There are lots of things we can do to improve our sleep hygiene, including not having caffeinated beverages late in the day or excess alcohol before bed. Turning down the lights and turning off electronics can also help you to get better sleep. And getting better sleep is really important, not only for migraine, but for stress reduction and general well-being.
