Neuroimaging still is "substantially overused" for outpatients with headache, and its use is increasing despite the publication of numerous guidelines recommending against it in this patient population, according to an analysis of data from the National Ambulatory Medical Care Survey.
Dr. Brian C. Callaghan of the department of neurology at the University of Michigan, Ann Arbor, and his associates sought to use the survey data to characterize recent trends in the use of CT or MRI for routine headache visits to primary care physicians (54.8% of visits), neurologists (19.9%), other specialists (12.9%), and non–primary care generalists (12.4%) in 2007-2010. They identified 51.1 million headache visits, including 25.4 million for migraine.
Neuroimaging was ordered for 12.4% of outpatient headache visits and 9.8% of migraine visits annually, at a cost of nearly $1 billion each year. "Total neuroimaging expenditures were estimated at $3.9 billion over 4 years, including $1.5 billion from migraine visits," they wrote (JAMA Intern. Med. 2014 March 17 [doi:10.1001 /jamainternmed.2014.173]).
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The yield of significant abnormalities on neuroimaging of headache patients is only 1%-3%, a rate that is comparable to that in patients without headaches, research suggests.
In a temporal analysis of the data, the researchers found that the rate of neuroimaging rose from 5.1% of all annual headache visits in 1995 to 14.7% in 2010. This increase occurred even though since the year 2000, "multiple guidelines have recommended against routine neuroimaging in patients with headache because a serious intracranial pathologic condition is an uncommon cause." Moreover, the yield of significant abnormalities on neuroimaging of headache patients is only 1%-3%, a rate that is comparable to that in patients without headaches.
"Perhaps guidelines have not curbed utilization because patients, as opposed to health care providers, may be the primary drivers of utilization," Dr. Callaghan and his associates said.
If so, efforts to better inform patients about unwarranted testing or to shift the costs of expensive, low-yield tests to patients may be more effective, they said.
This study was supported by the Katherine Rayner Program, the Taubman Medical Institute, the National Institute of Neurological Disorders and Stroke, and the Agency for Healthcare Research and Quality. Dr. Callaghan and his associates reported no relevant financial conflicts of interest.