Counter to guidelines, physicians increasingly ordering imaging for headache

Despite clinical guidelines, the use of advanced imaging for patients complaining of headaches has increased, according to a study published online Jan. 8 in the Journal of General Internal Medicine.

Nearly 12 million people each year visit physicians with headache complaints, costing nearly $31 billion annually, according to study authors, including John N. Mafi, MD, with Beth Israel Deaconess Medical Center in Boston.

In cases where the headache is not related to a known chronic clinical condition, evidence-based guidelines call for conservative treatments like stress reduction counseling or advice to avoid dietary triggers. Referrals for specialists or advanced imaging, the guidelines suggest, should be reserved for special circumstances such as cancer, trauma or other “red flags.”

“Despite broad agreement on these issues over the past decade, preliminary evidence suggests persistent overuse of these low-value services,” Mafi and colleagues wrote. “In this context, we used nationally representative data on ambulatory visits to clinicians to evaluate trends over the past decade in headache management in the office setting.”

The researchers studied 9,362 visits nationally for headaches between 1999 and 2000 and a second cohort from 2009 to 2010 (representing the estimated 144 million headache-related visits that occurred during the study period). They found that nearly three-quarters of the patients were female with a mean age of 46-years-old.

Mafi and team found that CT and MRI use rose from 6.7 percent in 1999-2000 to 13.9 percent in 2009-2010 and that referrals to other physicians rose from 6.9 percent to 13.2 percent.

On the other hand, counseling for headaches dropped from 23.5 percent to 18.5 percent during the study periods. Preventative medication usage rose from 8.5 percent to 15.9 percent while the use of opioids and barbiturates remained unchanged at 18 percent.

“The near doubling in use of CT or MRI represents an area of particular concern, given escalating efforts to control increasing costs in the U.S. healthcare system through decreasing or eliminating the use of low-value services,” the authors wrote.

Additionally, they noted that non-primary care physicians were more likely to order advanced imaging, consistent with the idea that it is the increase in referrals that is driving the increase in advanced imaging. The authors cited a recent study that found 62 percent of CT head/brain studies are inappropriate and this overuse comes with significant consequences like patient anxiety, additional invasive procedures and the risks of ionizing radiation.

The authors were encouraged by their findings related to medication.

“Unlike trends in the treatment of back pain, there has been no increase in the use of medications whose use is discouraged, such as opioids or barbiturates,” they wrote. “Nonetheless, both classes of medications continue to be used frequently, and represent an opportunity for improved management in the future.”

The management of headache, the authors concluded, represents an area of concern in the U.S. healthcare system and is an important opportunity to improve the value of patient care.