How to treat headaches isn't given much thought. There’s an alarming trend toward more costly imaging tests and medications.
More then 12 million Americans each year see their doctors over a headache. Many of those visits lead to expensive tests that are unnecessary and of little help, according to a study. You may be one of them, so think about the overall result.
For most headaches, evidence-based guidelines call for conservative treatments, such as counseling for stress and changing your diet, that can lessen their duration or prevent headaches in the first place.
“I was particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling,” says lead author John N. Mafi, MD, a fellow in the division of general medicine and primary care at Beth Israel Deaconess Medical Center in Boston, MA.
“These findings seem to reflect a larger trend in the U.S. healthcare system beyond just headache: over-hurried doctors seem to be spending less time connecting with their patients and more time ordering tests and treatments.”
Sometimes, just taking a complete medical history can lead a doctor to a treatable underlying cause, says Kathryn Boling, MD, a family medicine specialist at Mercy Medical Center in Baltimore, MD.
“Headaches can be triggered by a variety of situations. Some headaches are the result of tension in the neck and shoulders, some start due to sinus and allergy symptoms, and some are migraine headaches,” she says. “Some headaches are actually rebound headaches caused by daily or near-daily use of OTC (over-the-counter) headache medications.”
Boling says stress reduction techniques can reduce tension headaches, treating allergies and promoting sinus drainage can curb sinus headaches, and stopping the cycle of OTC drugs can decrease rebound headaches, often eliminating chronic daily headaches.
A report by Consumer Reports says “doctors often order tests and recommend drugs or procedures when they shouldn’t. In fact, near half of primary-care doctors say their own patients get too much medical care, according to a survey published by researchers at Dartmouth College. The Congressional Budget Office says that up to 30 percent of all healthcare in the U.S. is unnecessary.
As for CT scans and MRIs for headaches, the consumer watchdog magazine lays some of the blame at consumers’ feet, saying many want to see if their headache “is caused by a brain tumor or other serious illness. And doctors often comply to provide reassurance and to avoid lawsuits. But all that’s usually needed is a careful medical history and neurological exam. Adding a CT scan or MRI rarely helps.”
The Beth Israel study found just that, saying the authors’ analysis of about 144 million patients visits found a “persistent overuse” of low-value, high-cost services, such as advanced imaging and prescriptions of opioids and barbiturates.
At the same time, doctor counseling — which you should be getting in most cases anyway, rather than expensive tests and powerful drugs — decreased.
According to Stanford University’s Headache Clinic, lifestyle modification is often the “most important, beneficial” aspect of a treatment strategy that is going to vary from person to person.
“The goal is to maintain consistent sleep, eating and exercise patterns,” the clinic advises. “These three behaviors influence changes in your body's hormonal cycles. By maintaining consistency in these cycles, your body is better able to anticipate and adapt without spiraling out of control and into migraine.”
If that advice sounds familiar, the reason is that it forms the foundation of good health in general. You’ll hear it in connection with preventing diabetes, cardiovascular disease, and other serious health problems.
For more complex headaches, a diary can help identify triggers you can avoid in the future, says Mercy Medical Center’s Boiling. During a doctor’s visit, a physical with a complete neurologic exam can also guide treatment.
“In the face of a normal neurologic exam, a chronic headache history and no red flags, further testing in the form of imaging should not be necessary,” she says.
“Red flags would include acute onset of headaches, rapid increase in intensity and frequency of chronic headaches, being awakened from sleep by headaches, an abnormal neurological exam, head pain that is sudden or explosive, brought on by exertion, or a headaches accompanied by fever, a seizure, vomiting, loss of coordination, or a change in vision, speech, or alertness. In these cases imaging is indicated.”
Beth Israel’s Mafi believes that, often, a very conservative approach to treatment will make most normal headaches go away. He urges that you listen more to your body and, like Boling, pay close attention to the triggers.
You may have a misconception that fancy tests and referrals amount to better care, but Mafi says simple lifestyle counseling will often be more effective.
February 19, 2020
Christopher Nystuen, MD, MBA