Abstract
The appropriate imaging of patients with headache presents a number of important and vexing challenges for clinicians. Despite a number of guidelines and studies demonstrating a lack of cost-effectiveness, clinicians continue to image patients with chronic nonfocal headaches, and the trend toward imaging is increasing. The reasons are complex and include the fear of missing a clinically significant lesion and litigation, habitual and standard of care practices, lack of tort reform, regulatory penalties and potential impact on one's professional reputation, patient pressures, and financial motivation. Regulatory and legislative reforms are needed to encourage best practices without fear of professional sanctions when following the guidelines. The value of negative findings on imaging tests requires better understanding because they appear to provide some measure of societal value. Clinical decision support tools and machine intelligence may offer additional guidance and improve quality and cost-efficient management of this challenging patient population.
Highlights
In a study reviewed in the American Emergency Medical Journal, it was found that imaging of patients presenting to the emergency department during a 10year period (1998–2008) increased from just under 5% in 1998 to approximately 15% by 2008,19 despite the rate of significant intracranial pathology declining in the same period from about 10% to,5%
The analysis only found an incidence of brain tumor in 0.3% of patients, arteriovenous malformation in 0.07%, and saccular aneurysm in 0.07%; but it found a higher prevalence of white matter abnormalities reported on MR imaging of 12%–46%
Despite a number of guidelines and studies demonstrating a lack of cost-effectiveness, clinicians continue to image patients with chronic nonfocal headaches, and the trend toward imaging is increasing
Summary
The first proposals in the modern era for the classification of headache disorders were made in the 1960s by the National Institutes of Health and the Research Group on Migraine and Headache of the World Federation of Neurology.[9,10,11] the work emanating from these groups was limited in that the work merely constituted a listing of a relatively few headache disorders without diagnostic criteria, and the clinical utility was limited.[11]. Some years later Akpek et al[22] found similar results from a sample of 592 patients presenting with headache and no focal findings Their calculations yielded a cost per clinically significant case using marginal cost estimates of $23,400 ($41,528 in 2018 dollars). They found that the cost for the CT and ED visit was approximately 3 times the cost of a routine outpatient visit They found that the incremental cost per clinically significant case detected in the ED was $50,078 (2018 dollars).[24] Even in the pediatric patient population, cost-effectiveness of imaging of patients with headache and nonfocal neurologic examinations is lacking in lower-risk patients.[25]
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