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Unnecessary headache-related brain scans are on the rise, study finds

The scans, which are not without their risks, often are ordered to ease patients’ fears and to afford doctors legal protection.

Too many people who visit their doctor for a headache end up getting unnecessary — and potentially harmful — brain scans, according to a study published online this week in JAMA Internal Medicine.

The study also found that the number of these unnecessary scans has increased significantly in recent years — despite several national guidelines that specifically instruct physicians to order brain scans for patients with headaches only in rare circumstances.

In 2000, for example, the American Academy of Neurology released guidelines that advised against the use of routine brain scans on outpatients with headaches. And the American College of Radiology put imaging for uncomplicated headache on its “Choosing Wisely” list of top five medical tests that physicians and patients should question.

Brain scans — either magnetic resonance imaging (MRI) or computed tomography (CT) — are often ordered against the advice in these guidelines, however, to ease patient fears that the pain is a symptom of a more serious condition, such as a brain tumor or aneurysm. In addition, doctors may order the tests to protect themselves legally.

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Yet, as the authors of the new study point out, only 1 percent to 3 percent of the MRIs or CTs of people with chronic headache find evidence of a more serious condition. That’s about the same percentage that would be found if brain scans were given to patients without headache symptoms.

And unwarranted brain scans are not without potential risks. These dangers include the unnecessary radiation of the CT scans and the “incidental” findings (something that appears to be worrisome but which actually isn’t) that may lead to additional unnecessary medical tests and procedures.

Rate has almost tripled

For the study, a team of University of Michigan neurologists examined national data on brain scans and headache-related physician visits for the years 2007 through 2010. About half of those visits were for migraines, a severe and often debilitating form of chronic headache that is caused by a combination of genetic and environmental factors.

The data revealed that Americans made 51.1 million visits to their doctors for symptoms of headache during that four-year period. Most of the visits were by women (78 percent) and by people under the age of 65 (88 percent). More than half of the visits were to primary care physicians, and about one-fifth were to neurologists.

During those four years, 12.4 percent of the headache visits — and 9.8 percent of the migraine-related ones — led to either an MRI or a CT brain scan.

Using earlier data, the researchers also determined that the rate of headache-related doctor visits that end in a brain scan has almost tripled during the past 15 years, rising from 5.1 percent in 1995 to 14.7 percent in 2010.

Multiple ‘costs’

All of that unnecessary neuroimaging came with a cost, of course: an estimated $3.9 billion over the four years of the study — or about $1 billion per year.

And that’s a conservative estimate, according to the study’s authors, for it’s based on what Medicare pays for these tests, which is generally less than what privately insured (or uninsured) patients are charged.

But, as Dr. Mitchell H. Katz, deputy editor of JAMA Internal Medicine, noted in a commentary accompanying the study, the costs “that we should care most about as physicians are the unnecessary radiation (in the case of computed tomographic scans) and incidental findings that lead to unnecessary medical procedures and great anxiety on the part of our patients.”

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To reduce those costs, physicians need to help educate the public about headaches and the dangers of brain scans, he added.

“Although there will always be patients who will insist on having a test that is not supported by evidence, most patients are reassured when they feel their physician understands their condition and is working with them to develop a strategy for coping with the problem,” Katz wrote.

You can read the study in full on the JAMA Internal Medicine website. And the Choosing Wisely campaign offers some helpful information about imaging tests for headaches — when you need them and when you don’t.