Geographic variation in certified headache subspecialty availability in the United States

OBJECTIVES/BACKGROUND: Our objectives were to characterize the geographic distribution and local availability of United Council for Neurologic Subspecialties-certified headache specialists across US counties, hospital referral regions, and states, and to examine associations with socioeconomic deprivation, social vulnerability, and urbanicity. Headache disorders are highly prevalent and disabling, yet local availability of certified headache subspecialty care in the United States remains uneven. Although prior studies have described national and state-level distributions of United Council for Neurologic Subspecialties-certified headache specialists, important gaps remain in understanding county-level availability and disparities in access. Prior state-level summaries may mask within-state differences in access to United Council for Neurologic Subspecialties-certified headache specialists. METHODS: We conducted a cross-sectional geospatial workforce analysis of United Council for Neurologic Subspecialties-certified headache specialists in the United States as of January 7, 2026. Practice locations were mapped to counties, hospital referral regions, and states, and compared with general neurologist supply from the National Provider Identifier registry. Estimated population need was calculated by applying a national migraine prevalence to adult population denominators. We examined associations between specialist distribution and county-level socioeconomic vulnerability, urbanicity, and region. RESULTS: Among 3144 US counties, 2870 (91.3%) had no United Council for Neurologic Subspecialties-certified headache specialists, and 2085 (66.3%) had no neurologists. Headache specialists were entirely absent from counties without neurologists. Median county-level headache specialist density was 0 per 100,000 adults, reflecting the absence of local subspecialty care in most US counties. Accounting for county adult population, neurologist density, urbanicity, and region, higher Area Deprivation Index and Social Vulnerability Index scores were associated with lower headache specialist rates. Each 10-point increase in Area Deprivation Index was associated with lower expected headache specialist rate (adjusted incidence rate ratio = 0.87, 95% confidence interval = 0.82-0.93), and each 0.1-unit increase in Social Vulnerability Index was also associated with lower expected rate (adjusted incidence rate ratio = 0.94, 95% confidence interval = 0.90-0.98). Headache specialist availability relative to estimated population need varied markedly across counties, with substantial estimated local differences between migraine burden and certified subspecialty supply that were not apparent in state-level summaries. CONCLUSION: United Council for Neurologic Subspecialties-certified headache specialists are unevenly distributed across the United States, with limited local availability of certified headache subspecialty care in socioeconomically disadvantaged and nonmetropolitan counties. County-level analyses identified substantial local gaps in certified headache subspecialty availability that were not apparent in state-level summaries.