Overuse of brain scans for headaches persists, despite guidelines

Brain scans remain "substantially overused" on patients who visit the doctor complaining of headaches and migraines, despite multiple guidelines recommending against their use, a new JAMA Internal Medicine study says. Physicians must be vigilant about having conversations with patients about the risks, neurologists say.

Of more than 51 million U.S. patients who visited a primary-care physician, neurologist or other specialist for a headache, just more than 12% received an MRI or CT scan, according to the study which analyzed National Ambulatory Medical Care Survey data for all headache visits for patients 18 and older between 2007 and 2010. The data also found that of the more than 25 million who presented with a migraine, nearly 10% had undergone an imaging test. Use of neuroimaging was higher if the headache or migraine diagnosis was listed as the primary reason for the visit. During the four-year period, spending on the tests was estimated at $3.9 billion, according to the study.

“We were very surprised by the magnitude at which these tests were ordered,” said study author, Dr. Brian C. Callaghan, assistant professor of neurology at the University of Michigan. The trend since the mid-1990s has been that physicians increasingly kept ordering the tests, Callaghan says, despite evidence-based guidelines. “This is a big problem and something we need to take very seriously,” he said.

In 2000, a 14-member consortium led by the American Academy of Neurology released guidelines which advised against the use of routine brain scans on outpatients with headaches. Screening patients with isolated, nontraumatic headache by means of CT or MRI is not usually warranted, according to guidelines from the American College of Radiology. Though the guidelines exist, physician behaviors remain the same, Callaghan says.

“The point we're trying to make is that guidelines don't change physician behavior as much as we'd like them to,” he said. “Patients' expectations are to get MRIs and physicians want to satisfy their patients,” he says, noting that besides the risk of false positives and radiation exposure, there are ample financial implications to ordering unnecessary tests.

The Choosing Wisely campaign issued guidance in 2012 to help educate patients on potential radiation exposure and unnecessary treatment when using brain imaging for headaches and migraines, which the study says may be more effective than simply using physician guidelines. In an accompanying editor's note, Dr. Mitchell H. Katz, deputy editor of JAMA Internal Medicine, agreed.

“We need to focus more on educating our patients about headaches and the dangers of neuroimaging,” Katz said. His approach is to first acknowledge the patients' feelings so they are aware the symptoms are being taken seriously, and then he says he has their attention enough to speak about the potential harms.

“Although there will always be patients who will insist on having a test that is not supported by evidence, most patients are reassured when they feel their physician understands their condition and is working with them to develop a strategy for coping with the problem,” he wrote.

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