In 2012, the American Board of Internal Medicine (ABIM) Foundation launched a campaign called Choosing Wisely. The goal of the project was to encourage discussion about medical care that might be unnecessary or even harmful. Project leaders invited physician specialty societies to submit lists of five things that “physicians and patients should question” in order to make “wise decisions about the most appropriate care based on the individual situation.”
Last month, the American Headache Society (AHS) released a list of specific tests or procedures that are commonly performed but not always necessary in the treatment of Migraine and headache.
Here are the AHS recommendations and the reasons for each:1*
- Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for Migraine.
Numerous evidence-based guidelines agree that the risk of intracranial disease is not elevated in Migraine. However, not all severe headaches are Migraine. To avoid missing patients with more serious headaches, a Migraine diagnosis should be made after a careful clinical history and an examination that documents the absence of any neurologic findings such as papilledema. Diagnostic criteria for Migraine are contained in the International Classification of Headache Disorders
- Don’t perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.
When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure which may elevate the risk of later cancers, while there are no known biologic risks from MRI
- Don’t recommend surgical deactivation of Migraine trigger points outside of a clinical trial. The value of this form of "Migraine surgery" is still a research question. Observational studies and a small controlled trial suggest possible benefit. However, large multicenter, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery. Long-term side effects are unknown but potentially a concern.
- Don’t prescribe opioid or butalbital containing medications as first line treatment for recurrent headache disorders. These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches. They increase the risk that episodic headache disorders such as Migraine will become chronic, and may produce heightened sensitivity to pain. Use may be appropriate when other treatments fail or are contraindicated. Such patients should be monitored for the development of chronic headache.
- Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache. OTC medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, known as medication overuse headache (MOH). To avoid this, OTC medication should be limited to no more than two days per week. In addition to MOH, prolonged overuse of acetaminophen can cause liver damage, while overuse of nonsteroidal anti-inflammatory drugs can lead to gastrointestinal bleeding.
Dr. Elizabeth Loder, president of the American Headache Society and Chief of the Division of Headache and Pain in the Department of Neurology at the Brigham and Women’s Hospital in Boston, commented:
"All of us on the front lines of medicine know we have the opportunity to improve the care we deliver by engaging our patients in conversations about what care is really necessary and beneficial to their health. The recommendations in Migraine and headache treatment released today provide valuable information to help patients and physicians start important conversations about treatment options and make wise choices."2
Summary and comments:
The entire Choosing Wisely ® program is one that has been needed for quite some time. The increase in programs that increase productive communication between us and our doctors is far overdue. The Choosing Wisely ® program aims to promote conversations between physicians and patients by helping patients choose care that is:
- Supported by evidence
- Not duplicative of other tests or procedures already received
- Free from harm
- Truly necessary
Over the last several years, the American Headache Society has increased efforts to narrow that gap between patients and doctors. They’ve also increased efforts in the area of patient education through the American Headache Society’s Committee for Headache Education (ACHE) and with educational "Toolbox" content for patients from their journal, Headache.
Their recommendations of things that we patients and our doctors should question can, when followed, lead to better Migraine and headache care as well as increased communication between patients and doctors. Please be sure to read their reasons for each of these recommendations as each ultimately makes great sense.
What are your thoughts on these recommendations? Please post a comment below, and share them with us.
*** Please note:** As I often try to teach, a Migraine is not actually a headache. The headache of a Migraine attack, when there is one, is but one symptom of the attack, and a Migraine attack can occur with no headache. The field of medicine that addresses Migraine disease and other headaches became known as “headache medicine” many years ago and, unfortunately, the term headache is sometimes, as it is in the AHS recommendations, used interchangeably with Migraine or to include both Migraines and headaches.
1 The American Headache Society’s Choosing Wisely ® Task Force. “Five Things Physicians and Patients Should Question.” The American Headache Society. November, 2013.
2 Press Release. “American Headache Society Releases List of Commonly Used Tests and Treatments to Question.” American Headache Society. Scottsdale, Arizona. November 21, 2013.
3 Loder, Elizabeth, MD, MPH; Weizenbaur, Emma, BA; Frishbert, Benjamin, MD; Silberstein, Stephen, MD; on behalf of the American Headache Society Choosing Wisely ® Task Force. “Choosing Wisely in Headache Medicine: The American
Headache Society’s List of Five Things Physicians and Patients Should Question.” Headache 2013;53:1651-1659. doi: 10.1111/head.12233
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© Teri Robert, 2013
Last updated December 4, 2013.