Is headache training improving during neurology residency in Spain? A ten-year comparative study from the dual perspective of residents and tutors

Abstract

Introduction

Residency is a key stage for acquiring the clinical and research competencies required in neurology. Although headache disorders are highly prevalent and disabling, they do not always receive adequate attention during training. In 2015, a national survey revealed major gaps in headache training among neurology residents in Spain. This study aims to assess the current situation (2025) and compare it with previous data, while incorporating the perspective of residency tutors.

Material and methods

We conducted a cross-sectional, observational study based on an anonymous online survey distributed to neurology residents and tutors across Spain. The survey collected data on rotations, technical procedures, perceived quality of training, and research involvement. Current results were compared with those from 2015, as well as between residents and tutors.

Results

A total of 109 residents and 54 tutors participated. Eighty-eight percent of residents had rotated through a headache unit vs 48% in 2015. Forty-four percent reported being proficient in techniques such as botulinum toxin injections or nerve blocks vs 36%. Only 47% of residents considered their headache training adequate, compared to 83% of tutors. While 21% of residents had participated in headache-related research, tutors estimated this at 62%. Eighty-nine percent of tutors supported making headache rotations mandatory.

Conclusions

Although progress has been made over the past decade, headache training is still perceived as insufficient by many residents. We recommend implementing a mandatory rotation in headache, reinforcing hands-on training in technical procedures, and promoting structured research mentorship.

Resumen

Introducción

La residencia es una etapa fundamental para adquirir competencias clínicas y científicas necesarias en Neurología. Aunque la cefalea es una patología prevalente e incapacitante, no siempre recibe la atención formativa adecuada. En 2015, una encuesta reveló carencias importantes en la formación de los residentes de Neurología en cefaleas en España. El objetivo de este estudio es analizar la situación actual (2025) y compararla con los datos previos, integrando también la perspectiva de los tutores.

Material y métodos

Estudio observacional transversal basado en una encuesta online anónima dirigida a residentes y tutores de Neurología en España. Se recogieron datos sobre rotaciones, técnicas, percepción de calidad formativa e implicación en investigación. Se compararon los resultados actuales con los obtenidos en 2015 y entre tutores y residentes.

Resultados

Participaron 109 residentes y 54 tutores. Un 88% de residentes había rotado en cefaleas (vs. 48% en 2015). Un 44% dominaba técnicas como toxina botulínica o bloqueos (vs. 36%). Solo el 47% de los residentes considera adecuada su formación, frente al 83% de los tutores. Un 21% había participado en investigación en cefaleas, pero los tutores estimaban un 62%. El 89% de tutores apoyan la obligatoriedad de la rotación.

Conclusiones

Aunque se han logrado avances en la última década, la formación en cefaleas sigue siendo percibida como insuficiente por muchos residentes. Se propone incorporar una rotación específica obligatoria, reforzar el aprendizaje técnico y fomentar la investigación tutelada.

Introduction

Headache is one of the most frequent reasons for neurology consultations, and is one of the neurological disorders with the greatest healthcare and societal impact. In western countries, practically the entire population will experience headache at some time in their lives; migraine, in particular, affects 12%-13% of people (over 5 million people in Spain).¹ According to global burden of disease studies, migraine is the leading cause of years lived with disability in individuals younger than 50 years worldwide.² Despite this, there is evidence that headache has historically been underdiagnosed, undertreated, and potentially underestimated within medical training.³ Some neurology residents and neurologists in training have perceived headache as being “less neurological” or less rigorous than other subspecialties, partly due to its high prevalence and the subjective nature of pain.⁴ This historical perception of its lesser academic “value,” alongside the need to address a great amount of content within a limited training period (the duration of the neurology residency programme is 4 years), may have contributed to the fact that headache does not occupy a prominent position in all teaching programmes.

In Spain, the official neurology specialty programme⁵ (in effect since 2007) establishes among its general objectives that residents must acquire comprehensive competencies in the assessment of neurological patients and technical skills in neurological procedures, and that research in each area must be promoted. However, this programme does not explicitly include a mandatory rotation in headache units, nor a minimum level of practical training in this field, with this training being dependent on the particular organisation of each hospital. In 2015, due to suspicion of considerable variability and potential deficiencies in this field, the Spanish Society of Neurology’s (SEN) Headache Study Group (GECSEN, for its Spanish initials) conducted the first specific evaluation of headache training among Spanish neurology residents.⁶ This pioneering study of the perceptions of neurology residents revealed significant shortcomings in their headache training. Eighty-five percent of respondents considered the area to be undervalued within their training programmes, despite its status as one of the subspecialties attracting the most interest. More than half of residents performed no specific rotation in headache units, and only a third achieved competencies in such interventions as anaesthetic nerve blocks and botulinum toxin infiltration. Research activity was also scarce, with only 15% having contributed to some scientific project in this field. Overall, 40% considered their training in headache to have been insufficient. In the last decade, the field of migraine has seen continuous, significant advances, with the introduction of specific drugs targeting the calcitonin gene–related peptide (anti-CGRP) and advances in neuromodulatory treatments. In parallel, such techniques as anaesthetic nerve blocks and botulinum toxin infiltration continue to play a fundamental role in treatment approaches. These advances are transforming the therapeutic management of headache, and have led to considerable growth both in human resources and in the number of headache units; this has had a direct impact on the training of medical residents.

Analysis of the data collected in 2015 led to the decision to perform this comparative study to evaluate the achievements made and explore current perceptions. In this case, a dual perspective is analysed: that of neurology residents and that of their tutors (the figure responsible for teaching at hospitals), who also play a crucial role in the planning and supervision of residency training, and whose opinions and attitudes may directly influence residents’ opportunities for rotations in certain areas or for participation in research.

Material and methods

Study design

We conducted an observational, descriptive, and cross-sectional study using a self-administered survey distributed in May 2025 (the survey was open for a 4-week period, with a reminder sent at the halfway point). To enable comparison with the 2015 study, we included and added to the same questions as those used in the 2015 survey on headache training, incorporating the perspectives of residency tutors and knowledge about the management of the new therapies that have arisen over the last decade.

Population and sample

The target population were all neurology residents in Spain in 2025 (years R1-R4), and the tutors responsible for their training, at 82 nationally accredited hospitals. According to the national commission for the specialty, some 550-560 active residency positions exist. The survey was submitted to 557 e-mail addresses registered with the Spanish Society of Neurology, and both surveys were also disseminated by members of the GECSEN, with a view to achieving broad representation of the entire territory of Spain.

Data collection

The questionnaire included 20 closed-ended items (multiple choice or Likert-type), as well as open-ended questions. For residents, the following data were collected:

• •

  Sociodemographic data and year of residency.

• •

  Interest in neurological subspecialties.

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  Headache training resources at their hospital (clinic/unit, consultant neurologist).

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  Headache rotations (mandatory, elective internal, external, none).

• •

  Practical training in botulinum toxin infiltration and anaesthetic nerve block.

• •

  Participation in research projects and publications on headache.

• •

  Evaluation of the training received and perception of the field being undervalued.

• •

  Suggestions for improvement.

The questionnaire for tutors included parallel questions on the training structure, number of residents they tutor, adequacy of training, desire for the rotation to be mandatory, estimated participation in research, and evaluation of SEN courses.

Both complete questionnaires used in the study (the residents’ and the tutors’ questionnaires) are included in Supplementary materials 1 and 2.

Statistical analysis

Data were exported to Excel and analysed with the SPSS statistics software, version 25.0. Frequencies and percentages were calculated. To compare proportions between 2025 residents and the results from 2015, and between 2025 residents and tutors, the chi-square test and Fisher exact test were used, as appropriate. Values of P <  .05 were considered statistically significant.

Ethical considerations

The study was endorsed by GECSEN and approved by the SEN Scientific Committee. Participation was voluntary and anonymous, with confidentiality guaranteed and aggregated processing of data complying with the regulations in force.

Results

Participants

The survey was completed by a total of 109 residents (19.6%; 109/557) and 54 tutors, representing 15 of Spain’s 17 autonomous communities. By year of training, 12.8% of residents were in year R1, 26.6% were in R2, 34.9% were in R3, and 24.8% were in R4.

Training interests

Of the different neurological subspecialties, those attracting the highest number of residents were vascular neurology, epilepsy, multiple sclerosis, and headache. The same subspecialties were among the most valued in the previous study in 2015, although there were slight changes in the order of preference over time (Fig. 1). The main reasons for residents’ interest in headache were the broad spectrum of treatments (66.3%) and its high prevalence in everyday clinical practice (58.8%).

Figure 1.

Comparison of neurology residents’ interest in different subspecialties in 2015 and 2025. Values represent the percentage of residents selecting each field as one of their favourites.

Perception of headache being undervalued

Some 72% of residents considered headache to be undervalued in residency training (a 13% decrease with respect to 2015 [85%]) (Fig. 2).

Figure 2.

Comparison of key indicators among neurology residents in 2015 and 2025.

Rotations and training resources

In 2025, 88% of residents reported that they had completed a rotation at a specialised headache unit or clinic. Among residents who had completed a headache rotation, this was mandatory in most cases (73.4%); 12% of respondents had selected it as an elective rotation, and 1.8% as an external rotation. In 2015, only 48% of respondents had completed a headache rotation; thus, the current data show a marked improvement (Fig. 2).

The main forms of learning reported in 2025 were on-site training at the hospital (46.8%), attendance of specific courses (27%), and self-study (24%); only 1.8% reported that they had received no specific training. In 2015, only 10% of respondents reported that courses were their main source of learning; this difference reflects both the considerable increase in the courses available and the interest in these courses among resident neurologists as part of their training.

Despite these advances, 54% of 2025 residents continued to consider their training in headache to be insufficient; this percentage is higher than the 40% reported in 2015.

Technical skills

In 2025, 44% of residents reported that upon completion of their training, they were independently proficient in administering both botulinum toxin infiltration and anaesthetic nerve blocks; only 35.8% responded positively to the same question in 2015 (Fig. 2). It should be noted that not all respondents were in the final years of training; if we exclusively consider the question of whether the opportunity to learn both techniques was available during their residency, the percentage rises to 96.3%. This figure suggests much broader access, and coincides with the percentage reported by tutors.

For the first time, the 2025 survey included a specific question on the emerging anti-CGRP monoclonal antibody treatments. Only 11.9% of residents reported that they felt competent in using these drugs independently; no comparable data point is available for 2015, as these drugs were not part of everyday clinical practice at the time.

Research activity

With respect to research activity, 21.3% of residents indicated that they had participated in some research project on headache during their residency; 30% presented at least one poster or oral communication, but only 8.3% had collaborated in any scientific publication. Furthermore, 8% were working on their doctoral thesis at the time of the survey, with only 2% writing their theses on headache. Tutors, on the other hand, estimated that approximately 62% of residents were involved in research related to headache; this reveals a considerable discrepancy between the perception of instructors and the reality reported by residents (Fig. 3).

Figure 3.

Differences in the perception of 2025 residents and tutors of 2 fundamental aspects: the adequacy of headache training and the degree of research participation among residents.

Compared to 2015, research participation shows a slight increase: in the original study, only 15% of residents reported having contributed to some scientific project in this field. Regarding participants’ level of interest in research, 33% of 2025 residents reported that they had some interest, 53.7% were not very interested, and 13% had no interest in this research; the exact same percentage was reported in 2015 (Fig. 2).

In the overall assessment of the headache training received during the residency, only 47% of respondents considered this training to be adequate. In contrast, 83% of tutors considered the training provided in this field to be satisfactory (Fig. 3). This 36-point difference is particularly striking, and reflects a clear disparity between the perceptions of trainees and instructors.

Discussion

Our results reflect clear, but still insufficient, advances in headache training among Spanish neurology residents over the last decade. In 2025, 88% of residents had completed rotations at specialised headache units, as compared to 48% in 2015; 44% considered themselves proficient in such therapies and techniques as botulinum toxin infiltration and anaesthetic nerve blocks. These percentages are higher than those reported in the previous survey,⁷ and nearly as high as those reported for consolidated American programmes.⁸ Nonetheless, headache training was only considered adequate by 47% of residents compared to 83% of tutors; this reveals a gap in perceptions, underscoring the need for a more fluent dialogue about training and for continuous skills-based evaluation.⁹

The increase in rotations is related to the expansion of specialised consultations and positions promoted by the SEN and GECSEN; however, mandatory headache rotations continue not to be part of the official residency programme, a shortcoming previously described in the analysis of Spanish training units,¹⁰ which conflicts with the recommendation of the International Headache Society that at least 4 weeks of specific training be dedicated to the area.¹¹ Updating the national training programme and implementing an advanced training diploma in the future, as stipulated in Royal Decree 639/2015,¹² would enable unification of standards and a reduction in variability between centres.

Regarding technical skills, the proportion of proficient residents (44%) remains lower than the 60%-65% described by the directors of training plans in the United States.⁸ The limited opportunities for real-world practice and the short duration of some rotations partly explain this gap. It is essential to promote supervised, in-person training and clinical simulation. Furthermore, only 11.9% of residents felt prepared to manage the new anti-CGRP treatments, underscoring the need to update therapeutic training in the face of the rapid incorporation of innovative new treatment options for headache.¹³

Research participation continues to be a weakness: although the number of residents participating in research rose from 15% to 21.3%, it remains far below the 62% estimated by tutors and the threshold associated with consolidated academic activities.^4,14 The lack of time dedicated to research, competitive funding, and mentor roles explains this gap, and contributes to the global lack of headache specialists. Access to such collaborative networks as the European Headache Federation School,¹⁵ pan-European research training initiatives, and emerging intercontinental programmes^16,17 may bring Spain closer to international standards. A review of training programmes performed in compliance with the 2022 European Training Requirements in Neurology, which describe a 5-year training programme (2 years of general neurology, 2 years of neurophysiology/subspecialties, and one year of expanded clinical training or research), stressing updated competencies and learning objectives, may contribute to improving the weaknesses identified.¹⁸

The discrepancy between tutors and residents, both in their evaluation of training and their perceptions of research, underscores the need for tools for closer monitoring: electronic portfolios or periodic tutorials may enable timely detection of problems and adjustment of teaching, without bureaucratic overburdening of neurology departments. The fast pace and great quantity of content that physicians in training must learn often represent a challenge. However, the most efficacious methods of training tutors to perform this work remain unknown, and strategies are needed to improve tutors’ confidence in their ability to assess areas for improvement, understand active learning dynamics, and suggest appropriate study techniques during residency.¹⁹

Another relevant consideration is the COVID-19 pandemic, which represented an unexpected obstacle: nearly one-third of residents missed rotations in 2020 and 2021, slowing their learning of the techniques typically used in headache treatment and reducing in-person learning; residents who are currently completing specialisation were particularly affected.²⁰ Online teaching partly mitigated the impact of the pandemic, but competency in therapeutic procedures continues to require in-person training and supervision.

Besides training-related aspects, our findings may have a direct impact on clinical care. Insufficient training in headaches may translate to an ineffective clinical approach, diagnostic delays, or reduced patient access to specialised treatments. In contrast, adequate training of residents in this field promotes early identification of complex cases, timely provision of advanced treatments, and more decisive care from the hospital level, with the consequent benefits for the system and for patients.

Our study presents certain methodological limitations that should be considered. The response rate among residents was 19.6% (109/557), which may constitute a partial limitation for the representativeness of the sample, especially if those with greater interest or knowledge of headache were more likely to respond. Although the questionnaire was not formally validated, it was based on the instrument previously used in 2015, enabling longitudinal comparison. As the questionnaire was self-administered and some items were retrospective, we cannot rule out recall or response bias. Furthermore, there may be some over-representation of centres with greater involvement in headache, as distribution of the survey was supported by GECSEN members. Nonetheless, responses were received from 15 autonomous communities, and from varied types of centres, improving the robustness of the data. Finally, though data were based on self-reported perceptions, this information contributes a direct, valuable vision of the lived reality of residents and tutors across Spain.

Priority areas for improvement are introducing a mandatory rotation of at least 4 weeks (ideally, 8-12 weeks) at headache units, strengthening supervised practice of advanced techniques and new therapies, assigning an expert mentor at each training unit with real time allocated for tutoring research and professional development, introducing skill assessment tools and periodic interviews, and implementing the advanced training diploma described in the legislation to certify skills and attract talent to a subfield of neurology that continues to be the main cause of years lived with disability in people younger than 50 years.^2,3,21,22

Conclusions

The last decade has seen a substantial improvement in the headache training provided to Spanish neurology residents, with the majority now completing rotations at specialised units and an increasing number acquiring the most important technical skills. However, structural deficiencies remain, and there is a striking difference between the perceptions of residents and their tutors. Making headache rotations mandatory, strengthening practical training with robust programmes, and guaranteeing real pathways for mentorship and research are essential steps for ensuring that neurologists in training are fully prepared to attend patients with headache, a disease with an enormous clinical and social impact.

Funding

This study has received no specific funding. The study was promoted by the Spanish Society of Neurology’s Headache Study Group.

Acknowledgements

We would like to express our sincere gratitude to all neurology residents in Spain and to their tutors for participating in the survey that made this study possible. We are also grateful for the collaboration of the Spanish Society of Neurology, and particularly María José Saugar of the Scientific Section, as well as the Headache Study Group (GECSEN), whose support was essential in achieving the nationwide distribution of the survey.