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Editor's Note
May 2014

Coping With Headaches

JAMA Intern Med. 2014;174(5):821-822. doi:10.1001/jamainternmed.2014.33

It is not news that neuroimaging is overordered for patients with headache. In fact, as the authors have alluded to, the American College of Radiology, as part of the Choose Wisely campaign (ABIM [American Board of Internal Medicine] Foundation), has placed “Don’t do imaging for uncomplicated headache” on its top 5 list of things physicians and patients should question. However, because neuroimaging actually increased between 1995 and 2010 despite published guidelines discouraging the ordering of neuroimaging with simple headaches since 2000, the Editors thought the findings of this Research Letter are noteworthy.

As the authors demonstrate, the financial costs of neuroimaging for headaches are substantial. But the costs 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.

Because professional guidelines themselves appear to have limited impact on ordering of neuroimaging, we need to focus more on educating our patients about headaches and the dangers of neuroimaging. Headaches are frightening to patients and can conjure thoughts of brain tumors. It is therefore sensible that patients would seek neuroimaging to reassure themselves. Signs to us that the headache does not require further evaluation (ie, no change in the nature of headache for multiple years) may mean to the patient that the headache is serious (ie, it must be serious because I have had these pains for many years). If a physician simply says “you don’t need a scan” patients may think that the physician does not understand how great the pain is, or worse yet, that the physician is saving money for an insurance company.

I always begin my evaluation of patients with headache by acknowledging that headaches are frightening and can be disabling and that many people suffer from them their entire lives. I perform a thorough neurologic examination so that patients know that I take the symptom seriously, and if there are no neurologic deficits, I explain that we need to develop a strategy for dealing with the headaches because they are likely to recur. I explain that I do not want them to have neuroimaging because of the dangers of radiation and incidental findings. 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 that their physician understands their condition and is working with them to develop a strategy for coping with the problem.