Costly, Complex Headache Treatment on the Rise

By Shereen Lehman

(Reuters Health) - Contrary to most treatment guidelines for uncomplicated headaches, doctors are ordering expensive scans and referring patients to specialists more often, racking up unnecessary healthcare costs, a new study finds.

"In U.S. healthcare we have a general overtreatment problem and headache is no different except that with headaches a lot of the overtreatment is potentially low value and high cost," said lead author Dr. John Mafi, an internal medicine fellow at Beth Israel Deaconess Medical Center in Boston.

The great majority of people will experience a headache at some point in life, and about one in four Americans has recurrent severe headaches such as migraines. About 12 million Americans visit their doctors complaining of headaches each year at an annual cost of about $31 billion, Dr. Mafi and his colleagues write in a January 8 online article in the Journal of General Internal Medicine.

Most evidence-based guidelines for headaches advise conservative treatments such as counseling about stress reduction or avoiding dietary triggers for headaches, and reserve imaging or specialty referrals for "red flag" headaches that stem from neurologic problems, cancer, trauma, or HIV, the authors note.

"Oftentimes less can be more, particularly for things like uncomplicated headache where the vast majority of times they'll go away on their own with very conservative treatment and by listening to your body and really paying attention to the triggers," Dr. Mafi told Reuters Health.

Mafi thinks many people have a misconception that more referrals and tests equal better care than simple, but often effective, lifestyle counseling.

To analyze trends in headache treatment from 1999 to 2010, Dr. Mafi and colleagues looked at national healthcare databases. They examined more than 9,000 physician visits that were representative of the 144 million total visits for headache during that time period. The study team omitted visits for headaches associated with red flag conditions.

The researchers discovered that use of advanced imaging procedures such as CT scans and MRIs rose from less than 7% of visits in 1999-2000 to almost 14% in 2009-2010. Referrals to other physicians increased from about 7% to 13%.

The use of over-the-counter medications remained stable at approximately 16%, but use of anti-migraine medications such as triptans and ergot alkaloids rose from about 10% to more than 15%. Opioid and barbiturate use remained unchanged.

The study team also found that clinician counseling for lifestyle changes dropped from almost 24% of visits to less than 19%.

Dr. Mafi doesn't blame primary care providers, saying they're overworked, and there are financial and medico-legal pressures to order excessive testing procedures.

He thinks the current "20-minute model" of healthcare is broken and suggests moving toward one that reimburses electronic communications and secure messaging, along with patients' ability to enter their information online.

"There's less time than ever in the primary care visits because the doctors are increasingly hurried, it's just that much easier to click a button, order the test, and move on because it takes so much more effort and time to actually counsel the patient and to explain to the patient why a test is unnecessary," he said.

In their report, Dr. Mafi's team notes that the increase in the use of scans such as CT and MRI is "of particular concern" because of the added costs and potential harms of the scans themselves. In addition to the anxiety provoked in patients, scans may lead to unnecessary follow-up tests and incidental findings.

Moreover, contrast dyes used for some kinds of scans can provoke allergies or kidney problems, they note. Finally, they write, the unnecessary exposure to radiation is also a hazard, pointing to an estimate that 4,000 additional cancers were created by the 18 million head CT scans performed in the United States in 2007.

For busy clinicians, Dr. Mafi said, "One of the most important things that primary care can do is to stress nonpharmacological therapies, so just going over common dietary triggers like caffeine, chocolate, and alcohol."

He added that counseling patients on good sleep hygiene and stress reduction are also important. "And most important (counseling on) just leading an overall healthy lifestyle with a balanced diet rich in fruits and vegetables, and getting plenty of exercise."

Dr. Mafi said that having patients keep a daily diary of the events leading up to a headache is critical in helping to identify the patient's personal triggers.

"And when they can identify all the different triggers in their life, they can make active changes that actually prevent headaches from starting, which could actually lessen the need for more tests, medications, and even doctor visits," he said.

SOURCE: https://bit.ly/1Iqyktl

J Gen Intern Med 2015.

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