Choosing Wisely: 5 Headache Interventions Discouraged

November 21, 2013

The American Headache Society has released a list of specific tests or procedures that are commonly performed but not always necessary in the treatment of migraine and headache.

The list was developed as part of Choosing Wisely, an initiative of the American Board of Internal Medicine (ABIM) Foundation.

The recommendations are:

  • Don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.

  • Don't perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.

  • Don't recommend surgical deactivation of migraine trigger points outside of a clinical trial.

  • Don't prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

  • Don't recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.

The list was published October 29 in Headache.

When to Use Imaging

Elizabeth Loder, MD, president of the American Headache Society, told Medscape Medical News that the society had acted in response to the project by ABIM, which challenged specialist groups to look at various medical interventions that were overused.

"We sent a survey to our membership and asked them to come up with suggestions of procedures or medications that they thought were overused or thought to be low-value care, and from this list we selected five recommendations that were commonly cited.

"The American Headache Society encourages its members and all practitioners who treat people with headache disorders to help address the problem of low value care as we enter an age of medical scarcity and limited resources. It is important to think critically about the evidence for commonly used tests and procedures, and whether possible harms are likely to exceed potential benefits," the authors write.

On the first recommendation — don't perform neuroimaging studies in patients with stable headaches that meet criteria for migraine — Dr. Loder said, "We discouraged this practice as the likelihood of finding anything in these patients on neuroimaging is very low. And it is both costly and exposes patients to radiation. In addition, something incidental may be found which makes the patient worry excessively but has no serious implications."

Taking in the second recommendation, she added that imaging is advised when the headache is sudden in onset and becomes worse over time, but in this case MRI would be preferable to CT because it is not associated with radiation and picks up more underlying conditions.

Migraine Surgery Still Experimental

In the paper, the authors cite data from the National Ambulatory Medical Care Survey, which estimates that CT scans ordered at neurology visits (many of which were probably done to evaluate headache) resulted in costs of roughly $358 million.

Regarding the 2 medication-based recommendations, Dr. Loder said the discouragement of opioid or butalbital-containing medications was "simply a matter of which order therapies are used in."

She explained that opioids and butalbital impair alertness and may produce dependence if used frequently, so they are best reserved for situations when other medications, such as triptans or nonsteroidal anti-inflammatory drugs, have not worked or are contraindicated.

The advice not to use prolonged OTC medications is based on concerns that such medications are overused, which easily occurs when patients have frequent headaches and perceive that medications sold without a prescription are likely to be safe, Dr. Loder noted.

Taking too many OTC analgesics can also lead to "overuse headache" when headaches become worse. "So it is important that patients with frequent headaches discuss treatment options with their doctor."

And the recommendation on not to use migraine surgery outside a clinical trial was made because this is still considered an experimental treatment, Dr. Loder said.

Despite this, it is being offered to patients "by some people quite frequently" she added. She explained that standards required for surgical procedures to be used are not as stringent as those necessary for approval of drugs, and this is one example of a surgical procedure that is not supported by sufficient evidence to recommend its use routinely.

"All of us on the front lines of medicine know we have the opportunity to improve the care we deliver by engaging our patients in conversations about what care is really necessary and beneficial to their health.

"The recommendations in migraine and headache treatment released today provide valuable information to help patients and physicians start important conversations about treatment options and make wise choices," said Dr. Loder.

Headache. Published online October 29, 2013. Abstract

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