For Headaches, Clinicians Increasingly Ignoring Evidence-Based Guidelines
Clinicians are increasingly ordering advanced diagnostic imaging and referring patients to other physicians for the management of headache, despite recommendations in evidence-based guidelines against these practices. In a new study, a nationally representative sample identified 9,362 visits to clinicians for headache (excluding visits with “red flags,” such as neurologic deficit, cancer, or trauma) from 1999–2010; nearly 75% of patients were female and the mean age was 46 years.
Four main outcome measures were evaluated:
- Use of advanced imaging, including both computed tomography (CT) and magnetic resonance imaging (MRI)
- Referrals to other physicians
- Clinician counseling on lifestyle modifications during headache visits, including dietary and nutrition education/counseling, exercise education/counseling, and stress management and mental health education/counseling
- Use of medications including nonsteroidal anti-inflammatory drugs (NSAIDs, including COX-2 inhibitors), acetaminophen (including both prescription and over-the-counter NSAIDs and acetaminophen), preventive therapies (verapamil, amitriptyline, topiramate, or propranolol), abortive therapies such as triptans or ergot alkaloids, and therapies whose use is discouraged, such as opioids or barbiturates
Advanced imaging (including CT or MRI) increased from 6.7% of visits in 1999–2000 to 13.9% in 2009–2010 (p<0.001), although primary care clinicians were less likely to order CT/MRI. During the study period, referrals to other physicians also went up from 6.9% to 13.2%. Clinician counseling on lifestyle modifications actually declined from 23.5% to 18.5% while use of preventive medications increased from 8.5% to 15.9% and triptans and ergot alkaloids jumped from 9.8% to 15.4%. Use of NSAIDS and acetaminophen was consistent at 16%, as was opioid and barbiturate use which remained unchanged at 18%. Patients with migraine received triptans/ergot alkaloids and preventive therapies more frequently compared to patients with non-migraine headache and the use of opioids or barbiturates was higher for migraine headaches vs. non-migraine headaches (which remained unchanged over the study period).
Although the “Choosing Wisely” campaign of the American Board of Internal Medicine has encouraged a reduction in the use of advanced imaging and prescriptions for opioids and barbiturates for headache, these practices have actually increased over time. The authors of this study emphasize lifestyle modification counseling as a first-line treatment for the management of headache to improve healthcare and patient outcomes.