Study Finds CT and MRI Routinely Ordered for Headaches

Despite current guidelines that recommend against computed tomography (CT) or magnetic resonance imaging (MRI) for uncomplicated headaches, primary physicians have been ordering nearly $1 billion worth of scans annually, a new study has concluded.

During routine visits to a primary care physician, CT or MRI were ordered for 9.1 percent (95 percent CI 4.9 percent to 13.2 percent) of chronic primary headache patients, and for 13.6 percent (95 percent CI 5.6 percent to 22.8 percent) of migraine patients, according to research conducted by Brian C. Callaghan, M.D., of the University of Michigan in Ann Arbor, and his colleagues.

“Neuroimaging is routinely ordered even in common clinical contexts (migraine, chronic headaches, [in the] absence of red flags) where current guidelines explicitly recommend against its use,” Callaghan and colleagues wrote in a study they presented at the American Neurological Association annual meeting.

Guidelines from the American Academy of Neurology (AAN) and the European Federation of Neurological Societies (EFNS) on migraines have influenced the Choosing Wisely campaign, which has recommended against neuroimaging (CT or MRI) for uncomplicated headaches, the researchers noted.

Based on data on outpatient and office-based care from the National Ambulatory Medical Care Surveys (NAMCS), the researchers investigated the usage of neuroimaging in the United States for adult headache complaints from 2007 to 2010.

Excluded from the analysis were patients with the following non-headache “red-flags”: pregnancy, fever, AIDS/HIV, giant cell arteritis trigeminal neuralgia, epilepsy, cancer, and cluster headache.

Among 50.3 million outpatient visits for any type of headache, 12.4 percent were given a neuroimaging scan. For patients complaining of migraine, 9.8 percent were given a scan. A primary care physician ordered the neuroimaging scans, the data show.

Even researchers removed patients with risk factors for intracranial pathology, doctors still ordered scans for 12 percent of headache patients and 8.6 percent of migraine patients.

During routine visits to a primary care physician for a chronic primary headache, 9.1 percent were given a scan (95 percent CI 4.9 percent to 13.2 percent). Of patients with a flare up of an old headache problem, 13.6 percent were given a scan (95 percent CI 5.6 percent to 22.8 percent).

Primary care physicians ordered scans for 5.6 percent of chronic primary migraine during routine visits (95 percent CI 2.8 percent to  8.3 percent), and 8.6 percent of patients with a flare up of an old migraine problem (95 percent CI 3 percent to 14.1 percent).

According to Callaghan and colleagues, neuroimaging scans only yielded significant abnormalities in 1 percent to 3 percent of all patients with any type of chronic headaches.

Based on Medicare payment costs for these types of neuroimaging scans, these scans were estimated to have cost $975 million per year, which totaled $3.9 billion from 2007 to 2010.

Patients that were new to a medical practice were three times more likely to be given a scan compared with repeat patients (OR 3.2, 95 percent 1.4-7.5).

Callaghan and colleagues noted that physicians have reported patient reassurance as the top reason for ordering neuroimaging scans.