Limiting Neuroimaging Scans for Headache Recommended

Recent guidelines seeking to reduce the use of neuroimaging scanning for patients with headaches, to reduce the amount of radiation a patient receives from the scans, run the risk of missing or postponing the diagnosis of brain tumors, according to new data.

The study’s findings were published in the January 2015 issue of Neurosurgery, the official journal of the Congress of Neurological Surgeons. Neurosurgeon Dr. Ammar H. Hawasli and colleagues from Washington University School of Medicine, St. Louis (MO, USA), provided their viewpoint on recent guidelines suggesting limited use of computed tomography (CT) scans and other neuroimaging modalities for patients with headache. “Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” Dr. Hawasli and coauthors reported.

Lessening the use of neuroimaging for patients with headaches has been one focus of recent initiatives striving to limit the use of unnecessary and costly medical tests. Headaches are a typical complaint during physician visits. Migraine and other types of headache, in most instances, can be diagnosed in the physician’s office, without any special tests. “Nonetheless, neuroimaging in the United States, between 2007 and 2010, for migraines and headaches approached USD 1.2 billion,” according to Dr. Hawasli and colleagues.

Several groups have proposed recommendations to limit the neuroimaging for headache. For example, the “Choosing Wisely” guidelines developed by the American College of Radiology and the magazine Consumer Reports, include the recommendation, “Don’t do imaging for uncomplicated headaches.” However, from their experience in treating patients with brain tumors, Dr. Hawasli and coauthors have raised concerns about this recommendation. “Specifically, patients with brain tumors may present with isolated headaches in the absence of other neurological symptoms and signs,” they reported

The investigators examined a series of 95 patients with a confirmed diagnosis of brain tumor at their department. Almost half of patients had a combination of symptoms, such as seizures, cognitive and speech dysfunction, or other neurologic defects. However, approximately one-fourth had isolated headaches, no symptoms, or nonspecific symptoms.

In 11 patients, headache was the only symptom of brain tumor. Four of these patients had new-onset headaches that would have qualified them for neuroimaging under recently proposed guidelines. The remaining seven patients had migraine or other types of headache for which imaging may not have been performed under the proposed Choosing Wisely guidelines. Depending on which set of recent recommendations had been followed, neuroimaging would have been delayed or never performed in three to seven percent of patients with brain tumors.

That could have important implications for patient outcomes, as early diagnosis of brain tumors enables prompt treatment and a wider range of surgical options. “We support careful and sensible use of neuroimaging, in which physicians exercise excellent clinical judgment to reduce waste in the medical system,” Dr. Hawasli and coauthors wrote.

The neurosurgeons stressed the need for additionally study to develop “accurate and viable” guidelines on neuroimaging for headaches. The authors concluded, “Unvalidated guidelines to prevent neuroimaging in patients with headaches may reduce the perceived global economic burden at the expense of medical errors, delayed diagnoses, and inferior outcomes for patients with brain tumor.”

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Washington University School of Medicine, St. Louis