Headache neuroimaging and medication no-nos highlighted in new list


Patients with stable headaches that meet criteria for migraine should not undergo neuroimaging studies, according to one of five new recommendations developed by the American Headache Society about treatments and tests that may not always be necessary in the treatment of migraines and headaches.

The list of recommendations is part of the American Board of Internal Medicine Foundation’s "Choosing Wisely" campaign, which aims to educate patients and physicians about unnecessary and potentially harmful screening and treatment.

The AHS list was written by a task force approved by the AHS Board of Directors, in consultation with AHS members via an electronic survey.

The other four recommendations are:

• Don’t perform CT imaging for headache when MRI is available, except in emergency settings. "MRI is better for looking at brain tissue, and changes associated with migraines may be more visible on MRI," said Dr. Carolyn Bernstein, a headache medicine specialist and neurologist at Beth Israel Deaconess Medical Center in Brookline, Mass. In addition, "MRI doesn’t expose the patient to radiation, but the CT scan does."

• Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial.

• Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.

• Don’t recommend prolonged or frequent use of over-the-counter pain medications for headache. Though "abortive medications" such as Tylenol or Excedrin may be effective in relieving headaches and migraines, patients who take these medications too frequently may develop overuse headache, said Dr. Bernstein, who was not involved in making the recommendations. "People think it’s safe because it’s over the counter," she said. "But the headache can become harder to treat" and become refractory to the medications, leading patients to "ask for something stronger."

Dr. Bernstein recommends that patients track their headaches, either on a calendar or using a free smartphone app such as My Migraine Triggers or iHeadache. "If the frequency picks up and you find yourself reaching for abortive medication more than once a week, see a doctor and explore a preventative plan," she said.

This AHS Choosing Wisely list is being released along with its publication in the November/December issue of the journal Headache.

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