The American Headache Society (AHS) recently joined the Choosing Wisely initiative of the American Board of Internal Medicine in an effort to draw attention to tests and procedures that are associated with low-value care in headache medicine. An AHS committee of headache specialists produced a list of five such tests and treatments, and their methods and rationale were published in Headache. “We wanted the list to address common but often unnecessary or potentially risky tests and treatments for headache that in many cases do not represent evidence-based strategies,” explains Elizabeth W. Loder, MD, MPH, FAHS, who was lead author of the study.
According to the AHS, neuroimaging studies should not be performed in patients with stable headaches who meet criteria for migraine. In addition, CT scans should not be used in non-emergency situations as a diagnostic tool for headache patients when MRI is available. “MRIs can diagnose more underlying conditions that may cause headache that can otherwise be missed with CT,” says Dr. Loder. In addition, MRIs do not expose patients to radiation like CT scans. The recommendations note that MRI is of better value and safer than CT for migraineurs in all but a few emergency situations.
The AHS also recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. “The effectiveness of opioids is not in question,” Dr. Loder explains, “but these agents pose serious long-term risks and should be reserved for select patients. Effective long-term treatments will in most cases be necessary to manage this chronic disorder.”
In addition, the risk of dependency and abuse associated with opioid or butalbital-containing medications is of concern. Using these medications too frequently or for prolonged periods can also lead to medication overuse headache, a condition in which overused drugs actually make headaches worse. The AHS also recommends against prolonged or frequent use of over-the-counter pain drugs for headache. These drugs should not be used more than twice a week.
Surgery that targets migraine trigger points is still experimental and is not recommended outside of a clinical trial setting. “We need more evidence to clearly demonstrate that the benefits of surgery outweigh the potential harms or that it’s even helpful,” says Dr. Loder. “New drugs go through rigorous testing and must meet a certain standard before they’re approved for use. The same standard should be upheld for surgical interventions for headache. Until this research emerges, clinicians should think critically about the evidence for this and other commonly used tests and procedures and consider whether possible harms are likely to exceed potential benefits when discussing care with patients.”
Readings & Resources (click to view)
Loder E, Weizenbaum E, Frishberg B, Silberstein S; on behalf of the American Headache Society Choosing Wisely Task Force. Choosing wisely in headache medicine: the American Headache Society’s list of five things physicians and patients should question. Headache. 2013;53:1651-1659. Available at: http://onlinelibrary.wiley.com/doi/10.1111/head.12233/pdf.
Cassel CK, Guest JA. Choosing Wisely: Helping physicians and patients make smart decisions about their care. JAMA. 2012;307:1801-1802.
Silberstein SD. Practice parameter: Evidence-based guidelines for migraine headache (an evidence-based review): Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000;55:754-762.
Evans R. Diagnostic testing for migraine and other primary headaches. Neurol Clin. 2009;27:393-414.
Smitherman TA, Burch R, Sheikh H, Loder E. The prevalence, treatment and impact of migraine and severe headaches in the United States. Headache. 2013;53:427-436.
Bigal ME, Lipton RB. Excessive acute migraine medication use and migraine progression. Neurology. 2008;71:1821-1828.