Imaging Increasing for Headaches, Despite Recommendations

Advanced imaging may not be necessary for many people with headaches, but clinicians are ordering them for their patients.

Clinicians are ordering advanced imaging more frequently for their patients with headaches and are less likely to offer lifestyle counseling, according to a study published in the Journal of General Internal Medicine.

Researchers from Harvard Medical School, Beth Israel Deaconess Medical Center, and Massachusetts General Hospital in Boston sought to characterize trends in how headaches were managed between 1999 and 2010.

The longitudinal trends analysis looked at the use of advanced imaging (CT/MRI), opioids/barbiturates, and referrals to other physicians (guideline-discordant indicators), as well as counseling on lifestyle modifications and use of preventive medications.

The researchers identified 9,362 visits for headache, representing an estimated 144 million visits during the study period. Nearly 75% of patients were female, and patient mean age was approximately 46.

The findings showed that imaging, referrals, and use of preventative medications increased, while counseling decreased, and use of opioids remained steady:

Referrals to other physicians
Clinician counseling
Use of preventive medications
Use of opioids/barbiturates



Adjusted trends were similar, as were results after stratifying by migraine versus non-migraine and acute versus chronic presentation, the authors wrote. They also noted that primary care clinicians were less likely to order CT/MRI.[[{"type":"media","view_mode":"media_crop","fid":"30920","attributes":{"alt":"John N. Mafi, MD","class":"media-image media-image-right","id":"media_crop_53204269637","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3256","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"border-width: 0px; border-style: solid; margin: 1px; float: right;","title":"John N. Mafi, MD","typeof":"foaf:Image"}}]]

"I was particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling," lead author John N. Mafi, MD, fellow, division of general medicine and primary care, BIDMC, said in a release. "These findings seem to reflect a larger trend in the US health care system beyond just headache: over-hurried doctors seem to be spending less time connecting with their patients and more time ordering tests and treatments.”

The researchers concluded that, contrary to numerous guidelines, use of advanced imaging and physician referrals for patients presenting with headaches is increasing, while lifestyle counseling is being done less frequently than before.

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