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FROM THE AMERICAN HEADACHE SOCIETY: ‘Choosing Wisely’ 5 Things Neurologists and Patients Should Question about Migraine

Moran, Mark

doi: 10.1097/01.NT.0000442992.27539.0f
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As part of the American Board of Internal Medicine Foundation “Choosing Wisely” campaign, the American Headache Society highlighted five procedures related to headache that clinicians (and their patients) should question.

Imaging studies of patients with stable headaches that meet criteria for migraine, including computed tomography (CT) scans that expose patients to radiation, are among the most overused but unnecessary procedures performed for headache, according to recommendations by the American Headache Society (AHS) for the “Choosing Wisely” campaign. The recommendations were published in the November/December 2013 issue of the journal Headache.

The recommendation against imaging for stable, routine headaches that meet criteria for migraine is one of five released recently by the AHS. Other recommendations address the use of surgery for migraine, and the use of opioids and over-the-counter medications.

Physicians who spoke with Neurology Today say the Choosing Wisely recommendations are in line with guidelines for headache management established by the AAN, and with clinical wisdom. At least one expert, however, cautioned that clinicians should consider whether a patient has features that increase the likelihood of a secondary headache and thus increase the likelihood of a significant neuroimaging abnormality.

Choosing Wisely is an initiative of the American Board of Internal Medicine Foundation, in which national organizations representing medical specialists have been asked to “choose wisely” by identifying five tests or procedures commonly used in their field, whose necessity should be questioned and discussed. [The AAN released their recommendations for Choosing Wisely in February 2013. See “CHOOSING WISELY: 5 Things Neurologists and Patients Should Question”:]

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Elizabeth Loder, MD, MPH, president of the AHS, told Neurology Today that an eight-member task force developed the recommendations in consultation with AHS members, who received an electronic survey asking them to recommend items to be considered for the list. The task force reviewed a list of 11 candidate topics that had been developed from the over 100 suggestions received from AHS members. The final five items were selected based on commonly encountered situations in headache medicine associated with poor patient outcomes, low-value care, or misuse or overuse of resources.

“We tried to identify situations that are commonly encountered,” Dr. Loder said. “Some of these have been mentioned in other professional guidelines and other professional Choosing Wisely lists. Repetition is never a bad thing.

“We felt there was substantial evidence that patients who meet criteria for headache in the International Classification of Headache Disorders who have not had any recent change in their headache do not need neuroimaging,” she said. “In the vast number of cases it adds to the expense of care with no return or change in treatment.”

Stephen Silberstein, MD, a member of the AHS Task Force that developed the recommendations, noted that existing guidelines had referred to “uncomplicated” migraine — an ambiguous term that could be variously interpreted by clinicians. “What does uncomplicated mean? If the patient experiences an aura, does that make it complicated? And does that mean he or she needs imaging?”

A second AHS recommendation builds on the first: don't perform CT imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.

The AHS recommendations state that 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.”

Todd J. Schwedt, MD, associate professor of neurology at the Mayo Clinic in Scottsdale, AZ, told Neurology Today that the AHS Choosing Wisely recommendations are “clinically useful and important guidelines” for the diagnosis and treatment of patients with headache.

“The Choosing Wisely recommendation to not perform neuroimaging studies in patients with stable headaches that meet criteria for migraine is consistent with AAN evidence-based guidelines published in 2000,” he said. “Since the pretest probability of a clinically meaningful abnormality being found by neuroimaging is exceptionally low in the patient with a stable pattern of migraine and a normal neurologic examination, such patients do not require neuroimaging. However, the clinician must consider whether a patient has features that increase the likelihood of a secondary headache and thus increase the likelihood of a significant neuroimaging abnormality.”

These features might include abnormal neurologic examination, rapidly increasing headache frequency, focal neurologic symptoms, headaches causing awakening from sleep, new onset of headaches, rapid onset of an individual headache (the so-called “thunderclap” headache), older patient age, systemic symptoms, patient with underlying risk factors for a secondary headache (such as immunosuppression or cancer), headache worsened by the valsalva maneuver, and orthostatic headaches.

“If these features are present, neuroimaging will often be necessary,” Dr. Schwedt said.

The third AHS recommendation concerns migraine surgery, a procedure employed by plastic surgeons aimed at relieving peripheral nerve compression at various locations on the outside of the skull. Drs. Loder and Silberstein said patients should know there is insufficient evidence on the effectiveness and safety to consider this type of surgery an option in routine treatment of migraine.

And Dr. Silberstein added that migraine surgery is not usually covered by insurance, so patients are paying out-of-pocket for an expensive, unproven procedure.

The fourth and fifth recommendations concern use of opioids and over-the counter agents. The AHS recommends against prescribing opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

These medications impair alertness and may produce dependence or addiction syndromes, and they increase the risk that episodic headache disorders such as migraine will become chronic, and may produce heightened sensitivity to pain. Dr. Silberstein noted that patients who experience pain related to headaches often feel “if a little relief is good, a lot would be better,” leading to overuse and possible dependence.

But the recommendations state that use may be appropriate when other treatments fail or are contraindicated. “We don't intend to say that these medications are never appropriate,” Dr. Loder said. “But we think these should be treatments that are turned to later in the sequence of things that are tried.”

Finally, the AHS recommends against prolonged or frequent use of over-the-counter (OTC) pain medications for headache. “We believe physicians should have a conversation about any OTC medications patients may try for headache,” Dr. Loder said. “It may not be well appreciated that routine OTC use can actually aggravate headaches, so we want physicians to be alert and careful. Caffeine-containing medications when used occasionally in conjunction with aspirin or acetaminophen can improve outcomes, but when used too often can lead to rebound or medication overuse headaches.”

Dr. Loder said: “It is important to realize that we have specific treatments for headache of various kinds, unlike 20 years ago when all benign headaches were bunched together and treated with nonspecific pain-killers. This speaks to the importance of targeting treatment to the clinical presentation of the patient.”

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•. Loder E, Weizenbaum E, Frishberg B, et al. for 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(10):1651–1659. E-pub 2013 Oct 29.
    •. Neurology Today: From the AAN and the American Headache Society: How to Choose Migraine Therapies: Pointers from a New Evidence Review:
      •. Silberstein SD, Holland S, Ashman E, et al. Evidence-based guideline update: Pharmacologic Treatment for episodic migraine prevention in adults Part II. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1337–1345.
        •. Holland S, Silberstein SD, Ashman E, et al. Evidence-based guideline update: Pharmacologic treatment for episodic migraine prevention in adults Part I. Report of the Quality Standards Subcommittee of the American Academy of Neurology and the American Headache Society. Neurology 2012;78:1346–1353.
          •. More about the choosing wisely campaign:
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