Over 12 million Americans visit their doctors annually complaining of headaches and the real costs and estimates of lost productivity could be up to $31 billion annually.

What might help more people without spending more money? Fewer tests and some counseling about lifestyle changes.

An analysis of more than 9,000 physician visits for headaches between 1999 and 2010 found that, rather than talking to patients about the causes and potential sources of relief from headache pain, clinicians ordered advanced imaging and providing specialist referrals, both of which are considered to be of little value in the treatment of routine headaches. Are they routine? In that same time period, defensive medicine to protect against malpractice lawsuits and a teach to the protocol environment to obey government rules and get paid became the norms.

Medicine has been left behind, but is it doctors who want to abdicate common sense?

The assessment of headaches depends on identifying the relatively rare instances where serious underlying causes are suspected, says lead author John N. Mafi, MD, a fellow in the Division of General Medicine and Primary Care at Beth Israel Deaconess Medical Center, who notes that evidence-based guidelines for routine headache, including those from the American Academy of Neurology, suggest conservative treatments such as counseling on stress reduction or avoiding dietary triggers. The American Academy of Neurology, of course, is not in charge of paying insurance company or government invoices so doctors often do what the protocol says they must do. Yet Mafi believes that the crunch in general practitioners due to increased Medicare recipients - doctors overwhelmingly recommend that smart people who are medically inclined become nurse practitioners instead of GPs - is not the problem and instead implies doctors are instead doing cookie-cutter treatment.

"I was particularly alarmed about the overall trend of more imaging tests, medications, and referrals alongside less counseling," says Mafi. "These findings seem to reflect a larger trend in the US 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. To me, this study suggests that the current 20 minute visit-based model of healthcare is broken and that we need to move towards promoting and reimbursing innovative solutions such as doctors and patients electronically collaborating on their healthcare outside the office visit." 

The paper analyzed an estimated 144 million patient visits, found a persistent overuse of low-value, high-cost services such as advanced imaging, as well as prescriptions of opioids and barbiturates. In contrast, the study found clinician counseling declined from 23.5 percent to 18.5 percent between 1999 and 2010. 

The use of acetaminophen and non-steroidal anti-inflammatory drugs like ibuprofen for migraine remained stable at approximately 16 percent of the medications. Meanwhile, the use of anti-migraine medications such as triptans and ergot alkaloids rose from 9.8 percent to 15.4 percent. Encouragingly, guideline-recommended preventive therapies - including anti-convulsants, anti-depressants, beta blockers and calcium channel blockers - rose from 8.5 percent to 15.9 percent.

Unlike with the treatment of back pain, researchers found no increase in the use of opioids or barbiturates, whose usage should be discouraged, although they were used in 18 percent of the cases reviewed.

Researchers also found a significant increase in advanced imaging such as CT scans and MRIs, from 6.7 percent of visits in 1999 to 13.9 percent in 2010. The use of imaging appeared to rise more rapidly among patients with acute symptoms, compared to those with chronic headache.

The data reflect a nationally representative sample of clinical visits for headaches from the National Ambulatory Medical Care Survey and the National Hospital Medical Care Survey. The data excluded visits with "red flags" such as neurological deficit, cancer or trauma.

Mafi notes that "despite the publication of numerous practice guidelines, clinicians are increasingly ordering advanced imaging and referring to specialists while less frequently suggesting first-line lifestyle modifications to their patients. The management of headache represents an area of particular concern for our healthcare system and stands out as an important opportunity to improve the value of healthcare in the United States."

The findings raise concerns on both a treatment and a cost basis, adds senior author Bruce Landon, MD, MBA, MSc, also of BIDMC. A 2010 report in the Journal of the American College of Radiology "found 62 percent of CT head/brain scans are inappropriate according to evidence-based guidelines, most frequently ordered inappropriately for chronic headache," he says.

This overuse has significant consequences, because incidental findings provoke unnecessary patient anxiety, can lead to more invasive procedures and often require follow-up testing."

The findings of the study were published online by the Journal of General Internal Medicine. In addition to Mafi and Landon, also of the Department of Health Care Policy at Harvard Medical School, authors include Roger B. Davis, ScD of BIDMC; Ellen P. McCarthy, PhD, MPH of BIDMC and the Office for Diversity Inclusion and Community Partnership at Harvard Medical School; Samuel T. Edwards, MD, section of General Internal Medicine, Veterans Affairs Boston Healthcare System; and Nigel P. Pedersen, MB, BS, of the Department of Neurology of BIDMC and Massachusetts General Hospital.

Mafi was supported by a National Research Service Award training grant (T32HP12706) from the US Health Services and Research Administration. Davis was supported by the Harvard Catalyst (NIH Award #UL T001102-01). Pedersen was supported by an NIH NINDS R25-NS070682-04 Award. No other disclosures were reported.