By: Dr. Geoffrey Modest
A rather disturbing article was published on trends in the ambulatory management of headache (see DOI: 10.1007/s11606-014-3107-3). This analysis looked at a nationally representative sample from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey (not including ER visits) and excluded those patients with red flags (neurologic deficit, cancer, trauma), with the following findings:
–9362 visits for headache assessed, which represents 144 million visits over the study period of 1999-2011
–mean age 47, 75% female, 75% white
–use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-10. The report did not differentiate CT vs MRI.
–referrals to other physicians rose from 6.9% to 13.2%
–but, clinician counseling declined from 23.5% to 18.5% (counseling includes: lifestyle modification, diet/exercise counseling, stress management, discussing potential psychosocial influences on headache)
–use of preventive medications increased from 8.5% to 15.9%
–use of opioids/barbiturates remained unchanged at 18% (which is higher than use of NSAIDs/acetaminophen, which was steady at about 16%, though triptans/ergots rose from 9.8 to 15.4%)
–trends not different if adjust for migraine vs nonmigraine headache, or acute vs chronic presentation
–primary care physicians (PCPs) had lower odds of ordering CT/MRI, though there was a parallel increase over time
In this context, Choosing Wisely published 5 suggestions in 2013, after this study period but highlighting previously circulated guidelines (see here), of which 2 were:
–Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine. Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in migraine. However, not all severe headaches are migraine. To avoid missing patients with more serious headaches, a migraine diagnosis should be made after a careful clinical history and an examination that documents the absence of any neurologic findings such as papilledema. Diagnostic criteria for migraine are contained in the International Classification of Headache Disorders.
–Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.
So, rather striking doubling of use of imaging studies (and, a recent report found that 62% of head CTs were inappropriate, according to guidelines) and referrals. It is good that more preventive meds are being used, though a little disturbing that so many opiates/barbiturates are still being prescribed. And, rather sad that clinician counseling decreased, as we continue to learn of the common psychosocial associations with headaches, though PCPs did somewhat better at that than non-PCPs. It is likely that part of the reason for decreased counseling is the increasing demands on PCP time (more to do/clinical items to address in a visit, more paperwork, more time pressure overall, and counseling takes more time than ordering a CT/MRI…). So, as an unabashed advocate of primary care, with its attendant deep patient relationships yet continual intellectual stimulation, I do need to rant a bit. This change in headache treatment is yet another example of the failure of our health care system: by its not placing primary care at the center of the system, with appropriate reimbursement to allow the PCPs to have time to address patients’ concerns adequately, the system not only misses an opportunity to decrease costs but also to significantly improve the quality of care.