Physicians Order More Imaging, Less Counseling for Headaches

It’s a common malady - each year more than 12 million Americans visit their doctors complaining of headaches, and millions more suffer without even seeing a doctor. Headaches are estimated to cost the US economy upwards of $31 billion each year in lost productivity. A new study by researchers at the Beth Israel Deaconess Medical Center (BIDMC) suggests that some of that cost could be offset if doctors ordered fewer tests and had an increased focus on counseling about lifestyle changes.

Their study found that clinicians are increasingly ordering advanced imaging tests and providing specialist referrals, instead of talking to patients about the causes of headache pain and potential sources of relief. Both imaging and specialist referrals are considered to be of little value in the treatment of headaches. 

The assessment of headaches depends on identifying the rare instances where serious underlying causes are suspected, said lead author John N. Mafi, MD, a fellow in the Division of General Medicine and Primary care at BIDMC. He notes that evidence-based guidelines for routine headaches suggest conservative treatments such as counselling on stress reduction and avoiding dietary triggers. 

"I was particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling," says Mafi. "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. To me, this study suggests that the current 20 minute visit-based model of healthcare is broken and that we need to move towards promoting and reimbursing innovative solutions such as doctors and patients electronically collaborating on their healthcare outside the office visit."

The study analyzed an estimated 144 million patient visits, finding a persistent overuse of low-value, high-cost services such as imaging, which rose from 6.7 percent of visits in 1999 to 13.9 percent in 2010. In contrast, the study found clinician counseling declined from 23.5 percent in 1999 to 18.5 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

Mafi notes that "despite the publication of numerous practice guidelines, clinicians are increasingly ordering advanced imaging and referring to specialists while less frequently suggesting first-line lifestyle modifications to their patients. The management of headache represents an area of particular concern for our healthcare system and stands out as an important opportunity to improve the value of healthcare in the United States. This overuse has significant consequences, because incidental findings provoke unnecessary patient anxiety, can lead to more invasive procedures and often require follow-up testing."