Imaging, specialists overused and counseling underused for headaches

Contrary to guidelines, the use of advanced imaging and specialty referrals for headache diagnosis treatment has increased in recent years, a study found.

Researchers used data from 1999-2010 in the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Survey to evaluate 9,362 visits to clinicians for headaches (which would extrapolate out to 144 million visits in the U.S. during the study period). Three-quarters of the patients were women, and the mean age was 46. Results were published by the Journal of General Internal Medicine on Jan. 8.

The use of advanced imaging (CT or MRI) increased from 6.7% of headache visits in 1999-2000 to 13.9% in 2009-2010, and referrals to other physicians increased from 6.9% of the visits to 13.2% in that same time. Meanwhile clinician counseling about potential lifestyle modifications decreased from 23.5% to 18.5%. The use of preventive medications, such as verapamil, topiramate, amitriptyline, or propranolol, increased from 8.5% to 15.9% during the study period, while prescriptions of opioids and barbiturates remained steady, at about 18%. Trends were similar when stratified by physician specialty (although primary care clinicians were about half as likely as others to order advanced imaging) or by migraine versus non-migraine.

The increase in imaging and referrals is inconsistent with practice guidelines on headaches and has broad cost and quality implications, the study authors noted. The referrals may have been responsible for some of the imaging, since primary care physicians were less likely to order it. The findings on medication use are more encouraging, although there is still room for improvement, the authors said. They speculated that the reduction in counseling may be due to physicians being increasingly pressed for time during patient visits. Overall, the results should be seen as an opportunity to improve the value of health care in the U.S., the authors concluded.