Limits on Neuroimaging for Headache Risky?

Megan Brooks

January 06, 2015

New "Choosing Wisely" recommendations that discourage neuroimaging for some patients with headache may lead to delayed or missed diagnosis of brain tumor, caution neurosurgeons from Washington University School of Medicine in St. Louis.

"Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon's experience with patients with brain tumor," Ammar H. Hawasli, MD, PhD, and colleagues write in a special article in Neurosurgery this month.

The American Headache Society's Choosing Wisely list discourages neuroimaging in patients with stable headaches that meet criteria for migraine. The American College of Radiology and Consumer Reports list discourages imaging in patients with uncomplicated headaches.

The investigators note that in their experience, patients with brain tumors may present with isolated headaches in the absence of other neurologic symptoms and signs.

To illustrate their point, the researchers performed a retrospective analysis of 95 patients with a confirmed diagnosis of brain tumor. Nearly half of patients (48.4%) had a combination of symptoms, such as seizures, cognitive and speech dysfunction, or other neurologic abnormalities. However, about one fourth (24.2%) had isolated headaches, no symptoms, or nonspecific symptoms.

In 11 patients (11.6%), headache was the only symptom of brain tumor. Four of these patients had new-onset headaches that would have qualified them for neuroimaging under the recently proposed Choosing Wisely recommendations, Dr Hawasli and colleagues say.

Yet the remaining 7 patients had migraine or other types of headache for which neuroimaging may not have been performed under the recommendations, they note. Depending on which set of recent recommendations had been followed, neuroimaging would have been delayed or never performed in 3% to 7% of patients with brain tumors, the researchers report.

"Although patients with headaches do not frequently harbor brain tumors, patients with brain tumors frequently present with isolated headaches or minimal symptoms. Therefore, the premise that brain tumors always present with more than headaches is incorrect. Assuming this false premise may lead to medical error," the investigators conclude.

Dr Hawasli did not respond to request for comment by press time.

Conversation Starter

Medscape Medical News asked Elizabeth Loder, MD, from Brigham and Women's Hospital in Boston, Massachusetts, for her thoughts on the paper. She is immediate president of the American Headache Society and led the task force that developed the American Headache Society's Choosing Wisely recommendations.

In an interview, Dr Loder noted that the Choosing Wisely project is intended to "start conversations, so in that sense this article is a welcome demonstration of the influence I think that Choosing Wisely has had. Unfortunately, I think it demonstrates a poor understanding of the purpose of the Choosing Wisely recommendations."

One concern Dr. Loder has with the article is the repeated use of the word "guidelines."

"The Choosing Wisely recommendations are just that, recommendations. They are not intended to be guidelines, which are developed through very complex long-term projects, but this article repeatedly refers to them as guidelines," Dr Loder said.

Another concern she has is the lack of detailed data on the retrospective case series. "There is no methods section, which is quite surprising to me when they purport to present data that contradict statements of professional groups," Dr Loder said.

It should also be noted, she said, that Choosing Wisely is "not a cost-cutting initiative. The purpose of the campaign is to reduce unnecessary care and medical waste."

"I think there are a number of reasons to be concerned about the view that this paper espouses, but I would also say it's very nice to see that the Choosing Wisely recommendations have had so much influence that people respond to them," Dr Loder added.

The study was supported by the Department of Neurosurgery at Washington University and grant funding from the National Institutes of Health. The authors have disclosed no relevant financial relationships.

Neurosurgery. 2015;76:1-6. Abstract


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