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Got A Headache? Study Finds Flaws In Treatment, 'Alarming' Rise In Imaging Tests

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Sometimes less really is more. A case in point: the treatment of routine headaches.

Doctors are increasingly ordering pricey, advanced imaging tests and referring patients to specialists, which, it turns out, offers little help to headache sufferers, a new study concludes.

Researchers from Boston's Beth Israel Deaconess Medical Center suggest that patients might be better served (and the health care system might save money) by instead focusing more on lifestyle changes for people seeking headache relief.

For the study, published online in the Journal of General Internal Medicine, researchers used a nationally representative database to analyze practice patterns among physicians treating headache patients.

I asked the lead author, John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at BIDMC, to sum up the bottom line results. Here (slightly edited) is his emailed response:

"...We found alarming rises in use of advanced imaging (CT/MRI), referrals to other physicians (presumably specialists), and a decline in first-line recommended life-style modification counseling, meant to prevent headaches. We also saw no change in use of discouraged medications, with opioids and barbiturates ordered in about 18% of visits throughout the study period.

These findings represent alarming trends in the management of headache, and to me, they reflect a larger trend in the U.S. healthcare system where over-hurried doctors are ordering more tests, more medications, more referrals to specialists and less time talking and connecting with their patients.

To me this suggests that the visit-based model of healthcare is broken,

and that we need to move beyond the confines of the office visit, which by the way is the main way that primary care doctors currently get paid in the US. We should be reimbursing care outside the visit using technology, such as doctors and patients collaborating on their online medical records, communicating electronically, as well as patients seeing their doctors virtually, during an e-visit for example. We need to preserve the office visit as an opportunity for doctors and patients to connect and build relationships, which to me is a critical strategy towards achieving better health outcomes.”

Here's more from the BIDMC news release:

Each year more than 12 million Americans visit their doctors complaining of headaches, which result in lost productivity and costs of upward of $31 billion annually. A new study by researchers from Beth Israel Deaconess Medical Center suggests some of that cost could be offset by physicians ordering fewer tests and an increased focus on counseling about lifestyle changes.

A new study of more than 9,000 physician visits for headaches between 1999 and 2010 found that, rather than talking to patients about the causes and potential sources of relief from headache pain, clinicians are increasingly ordering advanced imaging and providing specialist referrals, both of which are considered to be of little value in the treatment of routine headaches...

The assessment of headaches depends on identifying the relatively rare instances where serious underlying causes are suspected, says lead author, BIDMC's John N. Mafi, MD, who notes that evidence-based guidelines for routine headache, including those from the American Academy of Neurology, suggest conservative treatments such as counseling on stress reduction or avoiding dietary triggers...

The study, which analyzed an estimated 144 million patient visits, found a persistent overuse of low-value, high-cost services such as advanced imaging, as well as prescriptions of opioids and barbiturates. In contrast, the study found clinician counseling declined from 23.5 percent to 18.5 percent between 1999 and 2010.

The use of acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen for migraine remained stable at approximately 16 percent of the medications. Meanwhile, the use of anti-migraine medications such as triptans and ergot alkaloids rose from 9.8 percent to 15.4 percent. Encouragingly, guideline-recommended preventive therapies - including anti-convulsants, anti-depressants, beta blockers and calcium channel blockers - rose from 8.5 percent to 15.9 percent.

Unlike with the treatment of back pain, researchers found no increase in the use of opioids or barbiturates, whose usage should be discouraged, although they were used in 18 percent of the cases reviewed.

Researchers also found a significant increase in advanced imaging such as CT scans and MRIs, from 6.7 percent of visits in 1999 to 13.9 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

The data reflect a nationally representative sample of clinical visits for headaches from the National Ambulatory Medical Care Survey and the National Hospital Medical Care Survey. The data excluded visits with "red flags" such as neurological deficit, cancer or trauma.

Mafi notes that "despite the publication of numerous practice guidelines, clinicians are increasingly ordering advanced imaging and referring to specialists while less frequently suggesting first-line lifestyle modifications to their patients. The management of headache represents an area of particular concern for our healthcare system and stands out as an important opportunity to improve the value of healthcare in the United States."

The findings raise concerns on both a treatment and a cost basis, adds senior author Bruce Landon, MD, MBA, MSc, also of BIDMC. A 2010 report in the Journal of the American College of Radiology "found 62 percent of CT head/brain scans are inappropriate according to evidence-based guidelines, most frequently ordered inappropriately for chronic headache," he says.

This overuse has significant consequences, because incidental findings provoke unnecessary patient anxiety, can lead to more invasive procedures and often require follow-up testing."

Rachel Zimmerman Twitter Health Reporter
Rachel Zimmerman previously reported on health and the intersection of health and business for Bostonomix.

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