Author Insights: Neuroimaging for Headache is Overused and Provides Little Additional Benefit

Brian C. Callaghan, MD, MS, an assistant professor of neurology at the University of Michigan Health System in Ann Arbor, and colleagues suggest headache neuroimaging is common, costly, and overused. (Image: University of Michigan)

Brian C. Callaghan, MD, MS, an assistant professor of neurology at the University of Michigan Health System in Ann Arbor, and colleagues suggest headache neuroimaging is common, costly, and overused. (Image: University of Michigan)

Although most headaches are caused by benign conditions, sometimes they signal the presence of a more dangerous condition, such as a brain tumor or aneurysm. To determine if such a condition is present, a physician, often at the request of the patient, will order neuroimaging with computed tomography (CT) or magnetic resonance imaging (MRI).

But a research letter appearing Monday in JAMA Internal Medicine suggests neuroimaging for headache generally goes against current recommendations from multiple guidelines; is overused, costing the health system hundreds of millions of dollars; increases patient radiation exposure; and can detect incidental findings that lead to other tests and procedures for often benign conditions.

Using the National Ambulatory Medical Care Survey, the study authors found that from 2007 through 2010, there were 51.1 million adult headache visits, mostly to primary care physicians (54.8%); 88% were by patients younger than 65 years and 78% were by female patients. Neuroimaging occurred for 12.4% of all headache visits during that period, costing a total of $3.9 billion, and the use of neuroimaging for headaches has increased substantially in recent years, from 5.1% in 1995 to 14.7% in 2010.

Lead author Brian C. Callaghan, MD, MS, an assistant professor of neurology at the University of Michigan Health System in Ann Arbor, discusses his team’s findings.

news@JAMA: Why has the use of neuroimaging for routine headaches increased in recent years?

Dr Callaghan: My speculation is that imaging use in general has been increasing across the board as MRI and CT become more accessible. But the number one reason physicians give scans for headache is patient reassurance, not to detect a bad intracranial condition. The next reason is legal—physicians not willing to miss the very rare condition.

news@JAMA: Do reassurance and concerns about potential legal consequences have societal costs?

Dr Callaghan: The major problem is that we’re ordering lots of tests, and it’s a huge amount of money. Headache neuroimaging is one of the big-ticket items where we spend a lot of money, and we don’t get much bang for our buck.

news@JAMA: Why do patients seek reassurance, and is there a cost to seeking such reassurance?

Dr Callaghan: If you ask most patients who have had bad headaches why they want a scan, they would say that they worry about a brain tumor. But they don’t think about the other things that can harm them. They don’t appreciate some of the downstream consequences, like radiation exposure from CT or undergoing an MRI scan and getting a false-positive for something else that leads to more tests and procedures.

news@JAMA: How should physicians reassure patients who request imaging because they worry their headaches signal a serious condition?

Dr Callaghan: There are some circumstances where neuroimaging is warranted, but if the physician feels this is not one of those circumstances, he or she has to have a conversation with the patient to explain why the headaches are occurring and why an imaging test, with its potential side effects, is not warranted.



Categories: Computed Tomography, Headache, Magnetic Resonance Imaging, Migraine, Neuroimaging