Podcast: Migraine and the gender pain gap

Though it impacts all genders, migraine is sometimes misunderstood as a ‘women’s disorder’, which may lead to it being treated with less legitimacy, and presents barriers to diagnosis, treatment and research investment.¹

Gender stereotypes are known to contribute to gender bias in healthcare in general, and likely play a role in the gender pain gap – the phenomenon in which pain in women is more poorly understood and undertreated compared to pain in men.^2-4

Men are seen as being brave and rational, while women are seen as being dramatic, or to exaggerate to the extent that they are less likely to be believed about their pain. This extrapolates to the approach health professionals take to treating pain in women versus men, as they are more likely to refer women with pain for mental health assessments or to prescribe women antidepressants.^3,4

In this CPD-accredited podcast, listen to pharmacist Jacinta Johnson unravel how gender biases can impact treatment of migraine and hear first-hand insights from a patient on her long-term experience seeking treatment for migraine in the healthcare system.

It is likely that pharmacists will be involved in the management of migraine in both women and men. Therefore, they need to be aware of the potential for gender bias in healthcare as it pertains to migraine management so it can be better addressed and avoided.

This podcast explores the implicit biases that foster the gender pain gap, and how it can lead to insufficient pain management and patient care in migraine. Pharmacists will learn how they can prevent gender-based bias in their practice to ensure women receive appropriate pain management, as well as best-practice principles for the management of migraine.

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Transcript

Jacinta Johnson 00:00
Hi everyone. Welcome to this Australian Pharmacist’s CPD podcast titled Migraine and the Gender Pain Gap. My name is Dr Jacinta Johnson. I’m a senior lecturer in pharmacy practice at the University of South Australia and I’ll be your host today. I’m joining you from Kaurna country in the Adelaide Plains region and I’d like to acknowledge the connection that the Kaurna people have always had and will always have with this land and pay my respects to the Kaurna elders past and present.
Just before we start, I’d like to declare that this CPD activity is sponsored by Reckitt who make many of the products you’ll be familiar with in your pharmacies, noting that I can confirm that all content is true, accurate and independent opinion of myself and our guest speaker who I will introduce shortly. And the views that are expressed today are entirely our own.
So I’m excited to be talking to you about migraine today. It’s a topic that I am really passionate about. A lot of my previous research has been looking at new treatments for chronic headache disorders. And through this work, I got to really appreciate how important accurate assessment and effective migraine management is. It really can be life-changing for some people who experience these conditions. Today we’re discussing potential for gender bias in pain assessment and how it can affect the management of migraine with a focus on episodic migraine. We’re fortunate to be joined by Kim. Kim is a Sydney journalist with a lifelong experience of migraine both personally and with close family members and we’ll be hearing about those experiences today.
So to provide some context to kick things off, a 2023 national survey by Chronic Pain Australia showed that more than half of respondents, so 53%, felt stigmatised by healthcare providers. This stigma particularly affects women and members of the LGBTQIA+ community who suffer from chronic pain. Gender bias can have a broad impact on pain treatment as well, especially for women compared with men and with women receiving less accurate and intensive treatment than men, leading to suboptimal pain control and potentially longer hospital stays and higher medical costs. On that note, I want to take just a moment here to acknowledge the difference between the terms we’ll be using so gender terms women and men, and biological terms like females and males that refer to someone’s sex. Throughout the conversation today, usually the studies that I’ll be referring to have included women who are biologically female, and men who are biologically male. And we don’t have a lot of data on migraine experiences for transgender individuals or other gender-diverse groups. But in theory, some of the considerations that relate to female biology may also apply to those with female biology that don’t identify as women. So that’s just something to keep in mind as we discuss. So how does migraine fit into this context of gender bias and pain experiences? We know that women bear a disproportionate burden of headache disorders, accounting for over 60% of the total healthy life years lost to disease-related disability. This is supported by global data showing that women are more likely than men to live with migraines, especially between the ages of 35 to 44. And migraine is also debilitating for young women as per the Global Burden of Disability Diseases study. So it’s not a disease of aging. It affects women in what would usually be the most productive years of their life when they are working or they’ve got caring responsibilities.
So why is the gender gap, this gender pain gap, important to us? Pharmacists are often the first interaction with migraine sufferers, so it’s crucial that we’re aware of that potential for gender bias in health care, and we understand how gender stereotypes can influence migraine care.
In this podcast, we’ll explore practical ways to identify and to challenge potential biases, improving our knowledge on the gender pain gap and effective migraine care. So I’ve used the term gender pain gap a few times already. To clarify, the term gender pain gap refers to the differences in pain perception and treatment influenced by cultural and societal attitudes towards gender. This gap is particularly obvious in how women’s pain is often underestimated and undertreated because of these prevailing stereotypes. In the Chronic Pain Australia survey, three in four female respondents reported feeling ignored or dismissed when presenting with chronic pain. 62% reported feeling powerless or neglected. And 33%, a third of women, felt dehumanised. These are big, heavy terms. And I think they really highlight the huge impact that poor care can have on individuals’ pain experience and their wellbeing. So on that note, let’s turn to you, Kim. How were you treated when you first presented with symptoms of migraine? Did you feel your pain was taken seriously?

Kim Richards 04:53
My first experience of migraine would have been somewhere between the age of 10 and 12 years old. I had a father who suffered chronic debilitating migraine. And so I grew up in a house where it was very common to see this. So it was a long time before I actually had a conversation with a medical professional of any kind in relation to this. And when I first spoke to a doctor about it, I was told that it was likely to be an hereditary thing, and there wasn’t much you could do, and so on and so forth. So the times that I did a front up at a pharmacy, looking for some kind of pain relief, it was generally over-the-counter medications. And I spent a large proportion of my life managing quite significant migraine attacks, with very basic treatments. It wasn’t until my young son around the same age experienced a rather catastrophic migraine attack that left him paralyzed for three days that I had to then take action. And that was that experience that I then waded into communication at a much higher level right up to a neurologist that I discovered there was this entire world and experience that people had of migraine and treatments and research that I had just never, ever been exposed to.

Jacinta Johnson 06:23
Wow. I think that really drives home the importance about asking people when they do come into the pharmacy, about their headaches and more broadly, not just handing over the pain medicine they might be asking for, and really the role the pharmacist could have played for you in helping to navigate those different treatment options that you just didn’t even know existed. Sounds like at times your migraines were sort of treated by others as just a headache. Is that something you could relate to?

Kim Richards 06:53
Oh absolutely. There’s generally a lack of understanding in the community about the difference between a migraine, migraine attack and a headache and bad headache. I frequently will over my career see people call in sick to work because they have a migraine, that I’m not entirely sure they understand what a migraine and the difference between it. So I think that dilutes it more generally in society, because people don’t completely understand the difference,  and they’re profound, as you would know. So yeah, it wasn’t like I said, it wasn’t really until as a parent, and that I prioritise my son’s health, that I made all of these discoveries, essentially for myself.

Jacinta Johnson 07:34
That experience where people don’t really understand the nuances of what a migraine is and how it is different from a headache is something that I hear a lot from migraine sufferers, particularly women. They find that their family, friends, employers, even other health professionals don’t understand the impact that migraines can have on their lives. It’s not just a headache for a couple of hours that you move on from. It is a neurological condition, a syndrome that can have a prodrome, the headache phase and a postdrome and that can stretch across days for some individuals.
So what are the main biases to be aware of? It’s important to distinguish between explicit and implicit biases. So explicit biases are openly expressed attitudes while implicit biases are more subconscious, affecting our decisions and our actions without our knowledge, subconsciously. Implicit or the subconscious biases can manifest subtly through language, through looks, through little glances, impacting on how women may be perceived and may be treated in health care. For instance, males are often associated with having a high pain tolerance and being really stoic, while female norms allow for more pain expression. In my experience, this is particularly a strong stereotype in Aussie culture, where men working in really physical roles, farmers, tradies, they’re thought to be strong and they wouldn’t complain of pain unless it was really bad. So the perception can be that if they asked for pain management that their pain must be more serious. A study from 2001 shows that women’s pain reports are often underestimated or discredited due to differences in communication between genders, specifically a woman’s ability to verbalise emotions, leading to their pain being viewed with suspicion resulting in less aggressive treatment. These biases are also evident in different approaches in treating pain in women versus men by healthcare professionals, including women being referred to more services for mental health assessments and being prescribed more antidepressants. Male physicians tend to recommend activity restrictions for female patients more than male patients, suggesting that these gender biases are influenced by both the clinical characteristics of the patient but also the gender of the provider who is looking after the patient. Other studies have also shown that medical students, regardless of their gender, are more likely to provide women with nonspecific somatic diagnoses. So, Kim, you’ve obviously been heavily involved in your son’s treatment for migraine. Have you noticed any differences in how his treatment has been approached compared to your own experience?

Kim Richards 10:19
It’s a really illuminating question, because I had the same GP for 30 years. That GP has recently retired. But she was the one that I went to for my migraine. And I was given a sort of regime of paracetamol and ibuprofen. When I arrived at the same GP with my son and described it, we were immediately having MRI scans. We were off to the neurologist. There was quite a detailed treatment plan put together with drugs that at the time I couldn’t even pronounce. So it was a profound difference. It was a completely different conversation. So it’s interesting, and it’s only on reflection now that that I see those profound differences.

Jacinta Johnson 11:08
Yeah. Wow. So let’s dig a little bit deeper into the implications of the gender pain gap within health care. So the gender pain divide is a really stark reminder of the gender paradox in health. You might be familiar with the term or the phrase, women get sicker, but men die quicker, which just really highlights that despite the higher life expectancy that women have, they often live with many more years of morbidity and migraine can contribute to that. Population-based research shows that women experienced a higher prevalence of chronic pain conditions like migraine compared to men, which may be exacerbated by these gender biases in pain treatment that we’ve just heard about from Kim. Gendering of diseases, particularly in the context of migraine, like labelling migraine as a woman’s disorder can exacerbate workplace antagonism as well. And that increases the gender bias further. The gender pain gap impacts on patient outcomes in a multifaceted way. Poorly controlled pain can lead to psychological stress that can change cytokine levels, the inflammatory mediators in our blood, can elevate cortisol levels and can depress the immune system. And that can increase that risk of acute pain transitioning to chronic pain. from acute migraine to chronic migraine, and that can further lead to functional decline, really impacting even more on someone’s quality of life. Gender biases and stereotypes influence how healthcare providers interact and treat their patients leading to differences in quality of care received by those patients based on their gender.
So let’s look now at migraine in women in more detail. Migraine, which is three times more common in women than men is often portrayed in the media as an ailment of these frail and perfectionist woman. And this misrepresentation not only underplays the really disabling nature of the condition, but can perpetuate those gender pain gap influences further by reinforcing the stereotypes, and that can in turn limit the help-seeking behaviour and limit a woman’s ability to receive appropriate care. What’s really interesting, I think, is that these stereotypes can also impact on men. So men who have migraine might actually avoid seeking treatment for the condition because it’s seen as a woman’s illness. And this is often echoed in pharmaceutical advertisements that will commonly depict migraine as a predominantly female disorder, ignoring that significant number of men that are affected by the condition. These stereotypes also extend into the treatment of chronic pain more broadly, particularly for members of the LGBTQIA+ community. The Chronic Pain Australia survey reported that over half so 52% of the LGBTQIA+ respondents in that survey, felt stigmatised by a GP and 63% felt stigmatised by other healthcare professionals. While our understanding of migraine experiences in these gender-diverse groups, including those who are transgender, gender fluid or gender non-binary, is limited. But as we learn more about this patient cohort that may change in the future.
We mentioned at the start of this podcast that as pharmacists, we are really important in helping guide patients through their migraine management. Often, like Kim was saying earlier, patients themselves are self-medicating and they really do rely on pharmacists’ advice to navigate the treatment process. According to a study from 2018, only 45.5% of individuals with episodic migraine and just 41% of those who have chronic migraine actually sought consultation from a healthcare professional, with just 39% of episodic and 10% of chronic migraine cases actually getting a proper diagnosis and the appropriate treatment.
As we discussed, women report greater disability due to migraines. This includes more frequent attacks and longer recovery periods from those attacks. However, women also face increased barriers in receiving accurate diagnosis, especially for menstrual migraine, which is a really common subtype of migraine in women. The lack of education and awareness around menstrual migraine poses additional challenges for women and obtaining effective diagnosis and treatment. And this is where it does get particularly complex because it’s not just gender bias that influences how women experience migraine. There are also many physiological differences that increase not only migraine prevalence for women, but also the migraine experience and the suffering that women go through with this condition. Hormonal factors significantly influence migraine pathogenesis. We know migraine is far more prevalent through the lifetime for women, it peaks for both women and men at approximately 35 years of age and again that 50 years of age.
Oestrogen we know influences migraine onset, with migraine attacks usually being linked to declines in levels of oestrogen so for women as their period is approaching as their oestrogen levels drop off. That’s often a trigger for migraine attacks, particularly in those with menstrual-related migraine syndromes. Other patterns that demonstrate this evidence includes a high prevalence of women with menstrual-related migraine changes in migraine, usually an improvement for a lot of women occur with pregnancy and then with menopause later in life as well. And interestingly, we also know that nausea, photophobia and phonophobia are more prevalent in women and women experience longer durations of migraine attacks with higher intensity. So Kim, while you are seeking treatment for migraine, how often if ever have healthcare providers referenced how hormonal factors including menstruation, or pregnancy could have influenced your migraines?

Kim Richards 17:15
Never is the short answer to that. After the birth of my three children each time, I went into a very extended period of cluster migraines every day, six weeks laying on the floor with a newborn baby, just on repeat these migraines and at the at the end of my third child when I approached my GP to sort of say, I’m not having any more children, what is the what’s the best contraception at this point in my life? Should I go back on the pill? And there was just like an epiphany moment where she said you should never have been on the pill, you have migraine with aura, you should never have been and I was literally on the contraceptive pill for 30 years while having migraine with aura. And it was after that, that I did the research and realised that that was a really big no, no. So I had never had any conversations in relation to that. That was really the only one.

Jacinta Johnson 18:18
Wow, that’s amazing to think that with 30 years of using hormonal contraception, which we know there’s really good evidence around the relationship with hormones and migraine, but it wasn’t even discussed with you.
I think that just highlights again, the broader implications of gender stereotypes in migraine management, they really can be profound. They can contribute to systemic bias in pain estimates. They can contribute to systemic bias in pain estimation and treatment and can interfere with equitable and effective care for all patients. So Kim’s experience hopefully brought home for us of those listening to this podcast how crucial it is to really listen to the patient not to make assumptions and to do a full assessment when someone does come to you with migraine regardless of their gender.
So following on from our discussion about these gender differences in migraine, we’re going to spend some time now discussing effective migraine management strategies as a pharmacist’s role in helping patients to work through the treatment options really is crucial. Firstly, if someone does present to your pharmacy with head pain, it’s important to screen for any red flags that might indicate referral to a GP as required. So some things to ask about include systemic symptoms, whether the onset of the headache or migraine was abrupt, if there are any changes to the headache pattern, how the headache responds to acute treatments or how it has responded in the past when the headache first started. So onset after 50 years of age or at less than 10 years of age would be uncommon for a typical sort of episodic migraine so that might trigger referral. You can also ask about medication overuse so how frequently are analgesics or other medicines used to abort migraines required, you can ask if they’ve started any new medications if they are experiencing a significant impact on their functioning. And if they’ve identified any triggers that might be related to their migraine. Pharmacists also need to be aware of the signs and symptoms of migraine so that it can be differentiated from other migraine types. It’s important to think about the frequency and the severity of headaches as well as the type of head pain and resources like the Australian Pharmaceutical Formulary and handbook or your APF is a good place to start for further information on that differential diagnosis process and screening for red flags. Of course, as for all over the counter consultations, you should ask about medical conditions and other medications the patient is using because there might be contraindications and drug interactions that might influence treatment options or that referral point. As Kim mentioned, the oral contraceptive pill could be an example there of something to screen for in someone who’s coming in with migraine, particularly if they mentioned aura.
Some patients might also require prophylaxis treatment for their migraines. So if they have very frequent migraines, particularly if they’re severe and they don’t respond to acute treatments, then a prophylactic agent may be beneficial for them. It’s certainly worth having that conversation. Typically, we would say a frequency of two or more migraines per month, but it really does depend on the impact those migraines are having on someone’s daily life. And for a lot of patients, they’re not aware that prophylactic agents even exist. They’re thinking about how do I relieve the pain at that point in time, perhaps completely unaware that there are medications that could be taken to reduce the likelihood of actually experiencing that pain in the first place. So as a pharmacist, letting them know that those options exist and referring them to their GP to talk about them can be really important. Extensive clinical experience also shows us that non-drug therapy, different non-pharmacological strategies, can be key components of migraine management, and they can provide some relief in reducing aura symptoms. So there are things you can do to reduce the likelihood of migraines, things like keeping good regular daily habits around sleep, hydration and exercise, and other lifestyle measures like relaxation techniques, physiotherapy, and even some complementary therapies that patients might find helpful. And then when the acute attack hits things like cold packs on the forehead, or the back of the skull, and hot packs over the shoulders, and also resting trying to get some sleep in a quiet dark room can provide acute relief, and they can be combined with medications for migraine as well.
Over-the-counter analgesics such as NSAIDs or aspirin are considered first-line therapy. Multiple NSAIDs can be trialled one at a time, potentially with an antiemetic before moving on to other treatments as response to one NSAID doesn’t necessarily predict the response to another. So if they try one and it doesn’t work, they can still try a different NSAID then that may be beneficial for them over the course of several migraine attacks. Acute treatment with non-opioid analgesics and antiemetics includes options like aspirin 900 to 1000 milligrams per dose, ibuprofen 400 to 600 milligrams per dose, diclofenac potassium at 50 milligrams per dose, or naproxen between 500 and 750 milligrams per dose, and paracetamol at one gram doses. You would usually repeat these doses over four to six hours as needed, depending on the product, adhering to, of course, the maximum daily limits. An antiemetic like metoclopramide could be added if response to those non-opioid analgesics is sub optimal.
In over-the-counter doses ibuprofen does act rapidly on an empty stomach. I think that’s sort of a myth that’s still out there in pharmacy practice. Often people were taught many, many years ago that ibuprofen or other NSAIDs must be taken with food. We know now that ibuprofen at the over-the-counter doses can be taken on an empty stomach.
After trialling non-opioid analgesics for a couple of migraine attacks, if they’re not effective, then it is possible to try different NSAIDs as we mentioned earlier, once you’ve worked through those, then a triptan may be an option. It is important to keep in mind of course, that for all acute headache treatments, there is potential for medication overuse headaches. So when you are speaking with patients about these options, you need to remind them to limit use of non-opioid analgesics to 15 or less days per month and for triptans, 10 or less days per month.
Alternatively, you can also use a combination of an NSAID and a triptan when treating migraine as well and some patients find that they do respond better to that combination than to either agent alone. If you are recommending a triptan the choice of triptan depends on several factors and tends to be refined along the way as you see a patient’s response to different agents. Naratriptan and eletriptan are sometimes better tolerated.
Patient education on how to use the triptans is important, including screening for additional risk factors that are specific to those drugs like cardiovascular risks and the medication overuse headache that I mentioned earlier. And regardless of the medication that you are recommending, educating patients on the correct usage, especially regarding dosing and administration is crucial for effective migraine relief. We also need to check in with patients regarding frequency of use, making sure they’re not using OTC medicines for extended periods. And for most agents taking the medication early in the headache phase of the migraine is recommended. Because we know that as the migraine progresses intestinal stasis tends to kick in, and that can interfere with absorption of the acute treatments.
As you probably deduced from this discussion, lots of trial and error is often required for managing migraine. So another way that you can help the patient to work through this trial and error process is to provide a printout of a headache diary or to prompt them to consider using a headache diary app. And they can use that headache diary to track what they have tried and what works for them. Kim, would you mind sharing with us now your experience of different treatments that you have used for acute onset and for prophylaxis of your migraines?

Kim Richards 26:42
Generally, now what happens to me as I’ve become older, is I get less of the headache pain. And the aura is much more pronounced. I will experience that Alice in Wonderland situation where I’m big and everything small or vice versa. And it’s in that moment that I now know is the best time to take anything and so I will take a combination of paracetamol and ibuprofen very, very quickly. If I catch it at that point, I will just experience aura for several hours and then a hangover. I take a combination of paracetamol and ibuprofen. And then I repeat that every eight hours. For my son it’s a very, very different situation. There’s triptans, there’s anti-nausea, and there’s another drug with an extremely long name that was prescribed actually in an emergency department. I was very fortunate when I fronted at an emergency department when he was unable to walk from the migraine that I actually came across an emergency doctor who had vast experience personal experience with migraine and was able to actually add an additional medication to this regime that really brought the length the duration of the attacks much much shorter. But most often with him he ends up on a drip in the hospital. His regime is incredibly different, but his pain threshold is possibly lower than mine, having lived with the experience of migraine for such a long time.

Jacinta Johnson 28:28
I think it really does just drive home how individualised migraine management is. Everyone that experiences migraine will experience it in a slightly different way and will respond to different medications at different times and throughout that experience. So thank you for sharing those details.
Let’s discuss some practical strategies to combat the gender pain gap in general and in migraine management. We’ve talked about the contribution of unconscious bias and to minimise the negative impacts that such unconscious bias can have, we need to first recognise it to make it conscious. Being aware of gender stereotypes is the first step towards mending inequality and pain care, stereotypes that can influence treatment decisions and patient-provider relationships are wide ranging even beyond gender. So things like age, race, and education levels can all subconsciously lead to these stereotypes that influence the way patients receive care. Awareness of implicit biases and correcting them can help to ensure that we treat the patient as an individual. And this behaviour change is key to overcoming most bias.
So there are several things that you can do to help train your brain to detect and to overcome that unconscious bias. One example is counter stereotyping. So that’s where you pick an individual you think about the stereotype that immediately comes to mind when you see that individual, and then you completely reverse it. So think about what the absolute opposite stereotype for that person would be and try to relate the two. Another way you can counteract unconscious bias is perspective taking. So that’s something as simple as watching a movie or a TV show or reading some material that is from the perspective of someone who is different to yourself. So in this case, maybe from another gender may help to, I guess help you to identify that unconscious bias as it pops up in your daily life. It’s important to adopt a holistic approach, which includes not discounting a patient’s subjective report of pain and being attentive to the emotional aspects. So moving away from that pure diagnosis-oriented approach, you know, the guideline says do X, Y, Z and thinking about personalised healing, asking the patient about what symptoms are bothering them most and tailoring the treatment to address the things that are actually important to the patient.
A diverse healthcare team can also help to address biases more effectively and to provide comprehensive care. So that’s something that you might think about if you’re responsible for hiring staff within your pharmacy. Engaging in clear objective conversations with colleagues can help to build trust with patients and with other healthcare professionals as well.
And there are unique aspects of migraine treatment, especially in transgender individuals due to the hormone use that require careful consideration, including secondary causes of headache, particularly that might be related to gender-affirming therapy. We know that it is a medical necessity and it is life-saving. So if there is a concern about potential interactions with pain conditions and pain treatment, then referral and adjustment to therapy is important.
Optimising pharmacists’ patient interactions is another key intervention to counteract gender bias and effective communication of pain management is key within this. Of course, our aim should be to improve the patient’s recovery, functionality and quality of life while minimising analgesic dependency. Critically, we need to offer patients privacy within the pharmacy. And that might include the ability to talk over the phone in some cases.
I’ve conducted lots of focus groups with consumers asking them about their experiences in pharmacies and concerns around privacy always come up time and time again. So if you are having a conversation with the patient, and there are others around thinking about moving that conversation to a private area. It’s also important to understand the impact of chronic pain on patients’ social and financial lives. Understanding that broader context of a patient’s life is vital for holistic care. Microaggressions, which are the everyday sort of subtle and intentional or unintentional behaviours that communicate some sort of bias towards marginalised groups, can also exacerbate the gender pain gap, so be aware of those microaggressions and ensure respectful communication with and about patients.
Patient education is key, specifically in pain management. Pharmacists should reassure patients, we should discuss self-management techniques such as early treatment and avoiding triggers for migraine, we should encourage regular reviews with their GP, particularly if migraines occur frequently, and refer the patient for migraine prophylaxis where appropriate as well, as well as for review of things like psychosocial factors like stress and sleep quality, which may overlap with pain symptoms like migraine and patients with migraine may also have other coexisting headache disorders like tension type headache or medication overuse headache as well. And patients who do receive a good explanation of their medications often report higher satisfaction. Psychosocial interventions like coping skills, training and support groups, spiritual and religious support are also useful for some patients in helping to restore their social function. So that’s something else you could raise during your consultations with patients.
As we mentioned with Kim’s scenario, every patient has a unique experience and every patient will require individualised care. It’s important to effectively relieve each patient’s pain and to prevent that transition from episodic to chronic migraine and to prevent medication overuse headache and over prescribing. So effective migraine management through assessing gender bias can be achieved by going through that individualisation process considering the variability in symptoms and the impact on patients’ quality of life. As pharmacists, we are skilled in taking comprehensive pain histories, either through patient-reported assessment outcomes, or by looking at headache diaries that the patient may be completing. And we can use those sources of information to address the gender disparities in pain management and identify those who might actually need referral versus management with over-the-counter medications.

Jacinta Johnson 34:52
Kim, can we ask now how as pharmacists, we can better support you in managing your migraines? Are there any ways that we could improve our communication to ensure that you feel heard that you feel understood and that you feel trusted?

Kim Richards 35:07
I think one of the most powerful things that the pharmacist can do for migraine is because that is often the first place anyone is going to go whether it’s their first migraine, or they’ve had, you know, years in my case, and a lot of the dot joining that you have to do as a patient to work out even to understand the variety of triggers that exist or the contraindications, with medications and the options available. I think it would be amazing to be able to have someone who could just comprehensively run through the list or the sort of process that you go through and that obviously you know for many patients would include talking to a GP or a, migraine specialist or so on and so forth. But I think I spent such a large number of years trying to join dots myself with various interactions of various people even seeking out other individuals who experienced migraine. That it took me a very, very long time to reach a place where I had a plan of action. And I think that that is incredibly powerful for pharmacists, because that’s the place you rock up and you know I’ve got a bad headache even that very first conversation of “Is it a bad headache? Or is this a migraine attack? Or is it something else?” For me that would have been life changing I think.

Jacinta Johnson 36:29
I think that really highlights that, as the pharmacist in migraine management. Actually only a small portion of what we do is supplying the medication. There’s a much bigger role for us in helping you to connect those dots to understand your condition, and to understand what supports and what options are out there for you to help with that migraine management. Let’s recap some key points and practical strategies for you to take away. Pharmacists play a pivotal role in addressing the gender pain gap given our easy access by patients, especially in migraine management. We’re often the first point of contact for patients more so than any other health care provider, positioning us really well to initiate change and to promote equitable care. Pharmacists need to have a heightened awareness of the existing gender biases due to the prevalence of stigma and discrimination in healthcare settings. Awareness of those implicit biases, educating fellow pharmacists and other healthcare professionals including the pharmacy technicians and assistants that you work with on these biases and actively striving to counter them in practice, is imperative. Educational initiatives focused on counter stereotyping or perspective taking can help to mitigate these biases, and foster enhanced empathy and a deeper understanding for the patients we care for.

Jacinta Johnson 37:51
There is a gender paradox where women despite experiencing more frequent and severe pain often receive less serious consideration and under treatment of pain compared to men. Future pain management strategies should consider the gender pain gap ensuring inclusive and comprehensive solutions. Remember that biases in health care do extend beyond gender assumptions based on age, race and education level can also influence pain management and intersect with gender biases. These wider implications need to be considered for a comprehensive approach in bridging the gender pain gap. Pharmacists should strive to improve the quality of communication with patients. This behaviour change is another really key factor in overcoming gender bias. We need to think about what assumptions we are making and really stop and listen to what’s important to the patient. Before we go ahead to recommend various treatments. We should act as the patient advocate and speak up about the gender pain gap.
So from here, I want to leave you with some notes for reflection:

• What unconscious biases have you observed in the pharmacy towards women in the area of pain management?
• Can you identify any courses or educational tools to increase your knowledge on the gender pain gap on implicit bias and on microaggressions? Because we know that awareness is the first step towards actively counteracting bias.
• And finally, what changes can you make in your own practice to ensure that you are addressing the gender pain gap in interactions with patients?

Thank you, Kim, for sharing your story today. And for those listening. Thanks so much for joining us. To complete CPD questions for this podcast please visit psa-ph.osky.dev

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Our speakers

Dr Jacinta Johnson, BPharm(Hons) PhD AdvPracPham GAICD FPS MSHP (she/her) is a credentialled Advanced Practice Pharmacist, Senior Lecturer in Pharmacy at the University of South Australia and Senior Pharmacist for Research within South Australia Pharmacy

Kim Richards is a patient who experiences migraines.

Content development

Tiruni Yasaratne

References

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