High Rate of Inappropriate Imaging for Headache

March 19, 2014

Around $1 billion per year is spent on neuroimaging for headaches in the United States, even though this is not recommended practice, a new study has found.

And although many sets of guidelines have recommended against routine neuroimaging for headache in recent years, referral for scans is actually increasing, the research shows.

The study, published online as a letter to JAMA Internal Medicine on March 17, was led by Brian C. Callaghan, MD, from the University of Michigan Health System, Ann Arbor.

"Headache is one of the top reasons for physician visits," he commented to Medscape Medical News. "Study after study has shown that it is very unlikely to find anything seriously wrong in patients with headache. Migraines and tension headaches are very common. Headaches due to brain tumors or aneurysms are very uncommon."

He adds that the bottom line for patients with headache who think they might want to have a brain scan is that if the doctor treating their headache doesn't think they need a scan, "don't push them."

Unnecessary Radiation

In an accompanying Editor's Note, Mitchell H. Katz, MD, editor of JAMA Internal Medicine, states: "[T]he costs we should care most about as physicians are the unnecessary radiation…and incidental findings that lead to unnecessary medical procedures and great anxiety on the part of our patients."

For the study, the researchers used the National Ambulatory Medical Care Survey, which characterizes all outpatient office-based care in the United States, to identify all headache visits for patients 18 years or older from 2007 through 2010.

Results showed that there were 51.1 million headache visits during those 4 years, including 25.4 million for migraines. Neuroimaging was performed in 12.4% of all headache visits and in 9.8% of migraine visits, at an estimated cost of $3.9 billion. The use of neuroimaging has increased from 5.1% of all annual headache visits in 1995 to 14.7% in 2010.

"In this study, 1 in 8 patient visits resulted in a referral for neuroimaging," Dr. Callaghan said. "But most patients have a few visits before they are referred, so we estimate that around half of headache patients are referred. This should be a much small number — under 10% would still be very conservative."

He explained that multiple guidelines have recommended against routine neuroimaging in patients with headaches because a serious intracranial pathologic condition is an uncommon cause. The yield of significant abnormalities on neuroimaging in patients with chronic headaches is just 1% to 3%.

He noted that the main reasons for so many referrals are patient reassurance and physicians' wanting coverage from a legal aspect. Part of the problem is the lack of clear consensus on exactly which patients with headache should be sent for neuroimaging.

"But in general there should be another reason as well as a headache to refer for imaging," he said. "This could be an abnormal neurological examination or certain other comorbidities. Patients are worried about brain tumors, but the likelihood of a brain tumor is in the same order of magnitude in patients with chronic headaches as in patients without headaches. Most patients with brain tumors do not present with headache."

New Strategies Needed

The researchers say more strategies need to be introduced to reduce the amount of neuroimaging performed in patients with headache. These could include better education of patients, requiring preauthorization for such tests, or transferring more costs to the patient.

"Given that headache neuroimaging is common, costly, and likely substantially overused, interventions to curb utilization of these tests have the potential to substantially reduce health care expenditures while improving guideline concordance. Therefore, optimizing headache neuroimaging practices should be a major national priority," they say.

In his Editor's Note, Dr. Katz points out that the American College of Radiology, as part of the Choosing Wisely campaign, has placed "Don't do imaging for uncomplicated headache" on its top 5 list of things physicians and patients should question, but this study shows neuroimaging actually increased between 1995 and 2010. In their Choosing Wisely list, the American Headache Society recommended against neuroimaging studies in patients with stable headaches that meet criteria for migraine.

When dealing with a patient with headache, Dr. Katz recommends always performing a thorough neurologic examination so that patients know they are being taken seriously, and then explaining that neuroimaging is not advised because of the dangers of radiation and incidental findings.

"Although there will always be patients who will insist on having a test that is not supported by evidence, most patients are reassured when they feel that their physician understands their condition and is working with them to develop a strategy for coping with the problem," he says.

JAMA Intern Med. Published online March 17, 2014. Letter   Editor's Note


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