Disturbing Trends in Headache Management

VBCN - May 2015 Volume 2, No 1

The treatment of headache for more than 12 million Americans costs more than $31 billion yearly. Some of this cost could be offset if physicians ordered fewer tests and counseled patients more about positive lifestyles, researchers from Beth Israel Medical Center, Boston, concluded (Mafi JN, et al. J Gen Intern Med. 2015;30:548-555).

John N. Mafi, MD, and colleagues identified 9362 visits for headache from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. Patients were excluded from this analysis if they had a neurologic deficit, cancer, or trauma. Nearly 75% of patients were female, with a mean age of 46 years.

Longitudinal trends analysis revealed that rather than talking to patients about the causes and the potential sources of relief from headache pain, clinicians often referred patients to specialists and ordered advanced imaging. Both of these approaches are considered to be of little value in the treatment of routine headaches, the researchers maintained.

“I was particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling,” Dr Mafi said. “These findings seem to reflect a larger trend in the US healthcare system, beyond just headache: over-hurried doctors seem to be spending less time connecting with their patients and more time ordering tests and treatments.”

Specifically, the researchers evaluated guideline-discordant indicators, including the use of computed tomography/magnetic resonance imaging (CT/MRI), the use of opioids/barbiturates, and referrals to other physicians, as well as guideline-concordant indicators, such as counseling on lifestyle modifications and the use of preventive medications (eg, verapamil, topiramate, amitriptyline, or propranolol). In addition, findings were stratified based on migraine versus nonmigraine headache, acute versus chronic symptoms, and whether the clinicians self-identified as the primary care physician.

The use of CT/MRI increased from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010 (unadjusted P <.001), and referrals to other physicians increased from 6.9% to 13.2% (P = .005). In contrast, counseling by clinicians declined from 23.5% to 18.5% (P = .041).

Although the use of opioids and barbiturates remained unchanged at 18%, the use of preventive medications increased from 8.5% to 15.9% (P = .001). Adjusted trends were similar, as were the results after stratifying by migraine versus nonmigraine and acute versus chronic presentation. Furthermore, primary care clinicians were 46% less likely than other physicians to order CT/MRI.

“Contrary to numerous guidelines, clinicians are increasingly ordering advanced imaging and referring to other physicians, and less frequently offering lifestyle counseling to their patients. The management of headache represents an important opportunity to improve the value of US healthcare,” the authors concluded.

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