Elinor K. Laffargue

Military sexual trauma (MST) is increasingly recognized in US veterans. MST is associated with psychiatric disease, substance abuse, and pain conditions, including headache. Little is known about the relationship between MST and specific headache disorders. This retrospective cross-sectional study analyzed administrative data from the Women Veterans Cohort Study, a sample of post-9/11 US veterans enrolled for Veterans Health Administration care. A positive MST screen in the electronic medical record defined exposure. We extracted demographic and clinical data from administrative coding for migraine and relevant confounders, comparing between subgroups with χ² tests. Health care utilization variables included designated sites of care and prescribed acute and preventive treatments and were evaluated with multivariable logit, negative binomial (nb), and zero-inflated nb models. Of 846,435 veterans screened for MST, 4.4% of veterans had a positive screen, whereas 9.5% had migraines. Veterans with migraine and a positive MST screen (21.7%) were more often non-White (45.3% vs 38.6%, p < 0.001), and 33 or less years old (55% vs 53%, p < 0.001) than veterans with migraine and a negative MST screen (9.0%). Adjusting for sex, the odds of migraine were greater for veterans with a positive MST screen (OR 1.62, 95% CI 1.57-1.67). Veterans with migraine and a positive MST screen were no more likely to receive triptan medications than veterans with migraine (46.2% vs 45.7%, p = 0.47) although were more likely to be prescribed opioids (36.1% vs 33.4%, p ≤ 0.001), compared with those with migraine and a negative MST screen. After controlling for sex, comorbidities (including chronic pain conditions), treatments, and other health care use, health care utilization was increased among migraine veterans with a positive MST screen, compared with migraine veterans without a positive MST screen for primary care (IRR 1.06, 95% CI 1.04-1.08, p < 0.001) and emergency department care (IRR 1.14, (95% CI 1.07-1.22), whereas neurology visits were not increased (IRR 0.97, 95% CI 0.92-1.02). Veterans with a positive MST screen constitute a vulnerable population more likely to have migraine, take opioid medications, and use emergency departments for migraine care.

Despite the importance of timely access to ambulatory specialty care, data regarding wait times to neurologists are largely lacking. This study examines wait times, and drivers of wait times, for new neurology office visits among commercially insured persons in the United States. We conducted a retrospective, repeated cross-sectional study using 2019-2023 data from the Merative MarketScan Commercial Database of approximately 20 million annual US enrollees. Enrollees with a new neurology visit, a primary care or emergency department (ED) visit in the prior 365 days, and continuous enrollment were included. The outcome was wait time in days for a new neurology visit following a primary care or ED visit. Mean (SD) and median (interquartile range [IQR]) wait times were reported by sex, race, neurologic condition, insurance type, and geographic region. Wait times were modeled using generalized estimating equations, clustering within metropolitan statistical areas (MSAs), and adjusted for demographic, insurance, clinical, and geographic variables. Between 2019 and 2023, 114,034 enrollees met our inclusion criteria, the mean age was 42.1 (SD = 16.1), and 65.6% were female. The average wait time for a new neurology visit was 49.7 days (SD = 65.4), and the median wait was 25.0 days (IQR = 9-62). Estimated wait times were shorter for female patients, compared with male patients (-7.0 days; 95% CI -7.8 to -6.2), and for stroke (-8.2 days; 95% CI -9.5 to -6.9), dizziness or vertigo (-7.8 days; 95% CI -10.4 to -5.1), and traumatic brain injury (-6.5 days; 95% CI -8.0 to -5.1) and longer for multiple sclerosis (+4.0 days; 95% CI 2.0-6.1). The Northeast Census region had the longest waits (+4.6 days; 95% CI 3.3-6.0). The proportion of non-Hispanic White race within a MSA was associated with reduced wait times (-0.2 days per MSA percent White; 95% CI -0.2 to -0.1). Enrollees with consumer driven health plans had the shortest wait times (-2.4 days; 95% CI -3.6 to -1.2). Neurologist density/100,000 enrollees was not associated with wait time (0.0 days: 95% CI -0.01 to 0.00). Wait times for new neurology appointments vary by sex, neurologic condition, insurance type, and geographic level variables.