Through the campaign Choosing Wisely, nine U.S. medical groups are urging doctors to reduce the use of 45 tests, procedures and treatments that may be unnecessary for patients. Each of these groups, which represent different medical specialties, created a list entitled “Five Things Physicians and Patients Should Question.” The one item that pertains to headache appears first on the American College of Radiology‘s list:
Don’t do imaging for uncomplicated headache.
Imaging headache patients absent specific risk factors for structural disease is not likely to change management or improve outcome. Those patients with a significant likelihood of structural disease requiring immediate attention are detected by clinical screens that have been validated in many settings. Many studies and clinical practice guidelines concur. Also, incidental findings lead to additional medical procedures and expense that do not improve patient well-being.
This recommendation makes logical sense and my rational mind agrees with it. However, I don’t know how well it will go over with patients.
There’s no scan or blood work that will prove you have migraine, which can be terribly unsettling. When someone has severe pain in their head, the immediate fear is that they have a brain tumor or aneurysm — you know, something scary and life-threatening. Getting a diagnosis of migraine without having any tests leaves people wondering if something was missed and if their life could be in danger. Negative MRIs and CT scans give patients peace of mind that migraine is the correct diagnosis. (I have no empirical evidence for this analysis, just eight years of interacting with terrified people who have headaches.)
Choosing Wisely’s guidelines do not tell doctors to refrain from testing in all cases, but provide “specific, evidence-based recommendations physicians and patients should discuss to help make wise decisions about the most appropriate care based on their individual situation.” The key here is that physicians and patients discuss the options.
I wonder if any conversation would have calmed my fears sufficiently for me to forgo my first MRI (or CT scan or MRA or spinal tap). I would like to think so, but before I became steeped in the migraine and headache world, practically all my encounters with headache were in movies, TV shows or books, where head pain almost always means brain tumor. Though the gigantic majority of all headache disorders are not life-threatening, society’s general take on headaches falls into two categories: no big deal and big, huge scary deal. For someone to see a doctor about headaches, they usually believe they fall into the latter category.
Tell me about your experience. Have you had imaging done for your headaches or migraines? Could you have accepted your diagnosis without the imaging?
I’ve had migraines and severe tension HA for quite a while now. When I had the first migraine, I went to my GP. I didn’t have any imaging because the doctors in the office said it would cost a lot, probably not aid in diagnoses, and would have no therapeutic benefit. They did run bloodwork, and they also gave me a list of neurologists that I could see if I felt it was necessary.
Thanks for sharing your experience, Gerald. I hope you’re able to find relief. I see that you’re at ASU, so we’re in the same area. Let me know if you want input on headache specialists in the area.
Take care,
Kerrie
I’ve had chronic migraines for a few months now and got an MRI and blood tests done. Not only was it really good to know that nothing else is wrong with me, but I am really fascinated looking at the pictures of my brain! I think if I hadn’t had the scan and tests done, I would have worried that something else is wrong with me. Now, with that out of the way, I can focus on working with my doctor to find a treatment that works for me. Here’s hoping we do find something that works!
Thanks for your input, Lisa. I hope you find something soon!
Take care,
Kerrie
I have been seeing my GP for a while for my headaches which she believe it’s just classic migraine. However, I do agree it can be unsettling with no concrete proof it is migraine and to rule out other scary stuff like a tumor. Afterall, one of the symptoms of tumor I believe is headache. I understand scans are expensive, but I rather spent the money and get a peace of mind.
After a sudden onset of migraines – w/in the 1st 3 months I was already having more than 20 days of migraines – I requested a MRI just to make sure there was nothing else going on. I heard from a few people around me that I was “lucky” to get referred out to a neurologist so early (w/in 1 month of the headaches starting). I didn’t feel so lucky with the pain I was feeling.
I feel like I’m boarder-line chronic, and if it weren’t for a fluke February, i think the doc would finally classify it that way too. I’m taking both Topamax & Elavil. I also just finished up my 2nd Medrol Dose Pack (took 1 early Feb, too). I don’t want to be taking that so often & this time I don’t feel like it’s given me any relief.
I’m new to all this. Finding your blog & others like it are helping me realize I’m not alone, that there are others out there that understand the pain I’m in, and that there is hope, eventually. It’s hard to think I’ve “only” been dealing with this for 6 months, but I just want some relief. I want to be able to hangout w/my friends & family without fearing their voices or laughter will bring on a migraine. I’m living a shell of the life I should be living.
Thank you for sharing your story. It does make a difference.
In my case I think the scan was medically necessary as I had a sudden onset constant headache, which could have been a tumor or something.
If its typical migraine, especially with family history, or typical headaches that happen to be more frequent than average, I would have to agree that the scan probably isn’t necessary. I bet its tough to convince patients of that though.
A lot of times doctors don’t explain that the scan can’t diagnose most headache conditions, just rule out some scary stuff (like a tumor or Chiari).
I agree how unsettling it is that nothing can prove I have this pain. Luckily I haven’t dealt with doctors not believing me…I know some have had this struggle (for example going into the ER and being treated as a drug seeker since their pain isn’t visible and can’t be proven). Best wishes.
I was diagnosed with chronic migraine last August, but after trying prophylactic medication after prophylactic medication (currently, I’m on Topamax) without hardly a change in my daily pain and many of the abortive drugs make me worse, I’ve certainly begun to wonder if chronic migraine is truly what is going on with me. My neurologist is beginning to think the same thing because he finally sent me for an MRI and an MRA a couple of weeks ago which thankfully came up negative. But for all this time, I’ve had in the back of my mind that there was something seriously wrong with me… which doesn’t help my headaches one bit! Having the imaging done definitely put my mind at ease… more than I had realized it would. It has been very difficult for me to accept a diagnosis based on a questionnaire with yes or no answers which I may not really know how to answer properly rather than scientific tests that are black or white. Especially since I don’t feel like my symptoms match what other migraine sufferers feel (my headaches are daily and pretty much always feel like I have a sinus infection, but they are very mild in the morning and get worse throughout the day). I have a few more tests in a couple of weeks to see if I have postural orthostatic tachycardia syndrome and to make sure I don’t have a heart problem. If those come up negative, then I’ll accept the chronic migraine diagnosis and hopefully we can find a prophylactic medication that will work.
I absolutely would have not been able to accept the diagnosis of cluster headaches with the imaging. I’ve had three MRIs w/ and w/o contrast in the past 7 years. I insisted on the last one with little pushback from my Neuro. Just because you can’t see it when you first get the damn headaches/migraines doesn’t mean whatever it is could be growing over time. It’s also a balance between cost and benefit. If it helps you accept the pain, I think it’s worth the cost of the imaging.