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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.

1 Comment for this article
CT Scans Are Not Dangerous
Mohan Doss, PhD | Fox Chase Cancer Center, Philadelphia, PA
This comment is regarding the recent article “Coping with Headaches” [1]. There is a common misconception in the scientific and medical community that even the smallest amount of radiation causes cancers, since most of our textbooks, expert advisory bodies, government panels, professional associations, experts, popular media, etc. have been conveying the same consistent message since the 1950s. Hence I was not surprised to read the concerns expressed in the article [1] about the radiation dose from CT scans with phrases such as \"we should care most about as physicians are the unnecessary radiation (in the case of computed tomographic scans)\", \"we need to focus more on educating our patients about headaches and the dangers of neuroimaging\" and \"I explain that I do not want them to have neuroimaging because of the dangers of radiation \". Despite the near unanimity of opinion regarding the carcinogenicity of low dose radiation in our community as described above, there is no credible evidence for increased cancers from low dose radiation. The evidence scientists used to quote for the carcinogenicity of low dose radiation [2] raising concerns about CT scans, and still continue to quote [3] (atomic bomb survivor data and 15-country study of radiation workers), are no longer valid because of updates to such data and analyses which have resulted in contradicting their previous conclusions [4]. Whereas high dose radiation is a well-known carcinogen, low radiation doses such as corresponding to multiple CT scans have in fact been observed to reduce the cancer risk in human studies, e.g. reduced second cancers (per kg of tissue) in radiation therapy patients in parts of body exposed to ~20 cGy [5], reduced cancer incidence in Taiwan apartment residents who were exposed to ~5 cGy due to contaminated steel used in the building [6, 7], and improved survival in non-Hodgkin's lymphoma patients who were given 10 or 15 cGy radiation dose to whole body or half body between standard radiation treatments [8]. In view of the above, I wish to suggest that physicians should allay patient concerns about radiation dose from CT scans by confidently stating that there is no evidence for any increased cancer risk from CT scans, but there is evidence for reduced cancer risk from radiation dose corresponding to multiple CT scans. Benefit to patient should be the sole criterion for performing a CT scan. If there is likely to be no benefit to a patient from a CT scan, this should be explained to the patient, and the CT scan should not be performed. Radiation dose should not be used as a reason for not performing CT scans. References:1. Katz MH. Coping with headaches. JAMA Internal Medicine. 2014 doi: 10.1001/jamainternmed.2014.33.2. Brenner DJ, Hall EJ. Computed tomography--an increasing source of radiation exposure. N Engl J Med. 2007;357:2277-84.3. Brenner DJ. What we know and what we don't know about cancer risks associated with radiation doses from radiological imaging. Br J Radiol. 2013. doi: 10.1259/bjr.20130629.4. Doss M. Radiation doses from radiological imaging do not increase the risk of cancer. British Journal of Radiology. 2014;87:20140085.5. Tubiana M, Diallo I, Chavaudra J, Lefkopoulos D, Bourhis J, Girinsky T, et al. A new method of assessing the dose-carcinogenic effect relationship in patients exposed to ionizing radiation. A concise presentation of preliminary data. Health Phys. 2011;100:296-9.6. Hwang SL, Guo HR, Hsieh WA, Hwang JS, Lee SD, Tang JL, et al. Cancer risks in a population with prolonged low dose-rate gamma-radiation exposure in radiocontaminated buildings, 1983-2002. Int J Radiat Biol. 2006;82:849-58.7. Doss M. Linear No-Threshold Model vs. Radiation Hormesis. Dose Response. 2013;11:480-97.8. Sakamoto K. Radiobiological basis for cancer therapy by total or half-body irradiation. Nonlinearity Biol Toxicol Med. 2004;2:293-316.