Your Dose of Medicine Despite guidelines, imaging ‘overused’ for headache

Neuroimaging still is “substantially overused” for outpatients with headache, and its use is increasing despite the publication of numerous guidelines recommending against it in this patient population, according to an analysis of data from the National Ambulatory Medical Care Survey.

The department of neurology at the University of Michigan, Ann Arbor sought to use the survey data to characterize recent trends in the use of CT or MRI for routine headache visits to primary care physicians (54.8 percent of visits), neurologist (19.9 percent), other specialist (12.9 percent), and non-primary care generalist (12.4 percent). They identified 51.1 million headache visits, including 25.4 million for migraine.

Neuroimaging was ordered for 12.4 percent of outpatient headache visits and 9.8 percent of migraine visits annually, at cost of nearly $1 billion each year. Total neuroimaging expenditures were estimated at $3.9 billion over four years, including $1.5 billion from migraine visits.

In a temporal analysis of the data the researchers found that the rate of neuroimaging rose from 5.1 percent of all annual headache visits in 1995 to 14.7 percent in 2010. This increase occurred even though since the year 2000, multiple guidelines have recommended against routine neuroimaging in patients with headache because serious intracranial pathologic condition is an uncommon cause.

Moreover, the yield of significant abnormalities on neuroimaging of headache patients is only one percent -3 percent, a rate that is comparable to that in patients without headaches.

Perhaps guidelines have not curbed utilization because patients, as opposed to health care providers, may be the primary drivers of utilization.

If so, efforts to better inform patients about unwarranted testing or to shift the costs of expensive, low –yield tests to patients may be more effective.