Headache is often over-investigated and overtreated, US study showsBMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h113 (Published 09 January 2015) Cite this as: BMJ 2015;350:h113
Opioids, barbiturates, and advanced imaging have been persistently overused to manage headache, says a US study of primary care and hospital outpatient consultations for headache from 1999 to 2010, while counselling of patients on lifestyle factors decreased.
Researchers studied 9362 consultations for headache over that time period from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey,1 which collect nationally representative data on patient visits to non-federal office based practices and hospital outpatient departments. The study excluded patients with “red flags,” such as fever, neurological deficit, cancer, or trauma.
Results showed that the use of advanced imaging such as computed tomography and magnetic resonance imaging increased from 6.7% of patient visits for headache in the year 1999-2000 to 13.9% in 2009-10 (unadjusted P<0.001). Referrals to other physicians increased similarly, from 6.9% to 13.2% (P=0.005).
By contrast, the use of counselling on lifestyle factors decreased, from 23.5% of patient visits in 1999-2000 to 18.5% in 2009-10 (P=0.041).
The use of preventive drugs increased from 8.5% to 15.9% over the study period (P=0.001). Treatment with migraine drugs also rose, from 9.8% of patients presenting with headache in 1999-2000 to 15.4% in 2009-10 (P=0.022).
The use of non-steroidal anti-inflammatory drugs and paracetamol remained stable over the time period studied, being used in about 16% of consultations for headache. Treatment with opioids or barbiturates also remained steady at about 18% of patient visits for headache, but the researchers considered that this was too high. Findings in patients with acute headache were similar to those in patients with chronic headache. Primary care physicians were less likely than their hospital colleagues to order advanced imaging, but drug choice was similar in both groups.
“I am particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counselling,” said John Mafi, lead author and a fellow in general medicine and primary care at the Beth Israel Deaconess Medical Center at Harvard Medical School, Boston, USA. “These findings seem to reflect a larger trend in the US healthcare system beyond just headache: over-hurried doctors seem to be spending less time connecting with their patients and more time ordering tests and treatments.”
Mafi noted that evidence based guidelines for routine headache recommend conservative treatments, such as counselling on stress reduction and avoiding dietary triggers. “The management of headache represents an important opportunity to improve the value of US healthcare,” he concluded.
Cite this as: BMJ 2015;350:h113
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