Patients who see a doctor for a migraine or headache often wind up getting costly brain scans that are unnecessary and may expose them to high levels of radiation, according to a new study published in JAMA Internal Medicine.
In an analysis of over 51 million headache related visits to physicians, researchers at the University of Michigan Medical School found that one out of eight visits resulted in an MRI or CT scan, at a total cost of about $1 billion a year.
Many of the brain scans were probably unnecessary, according to researchers, because of the very low odds that serious medical issues would be found in the patients’ brains.
“There’s solid research showing that the number of times you find serious issues on these scans in headache patients is about the same as that for a randomly chosen group of non-headache patients,” says Brian Callaghan, MD, the UM neurologist who led the team performing the study.
“And a lot of the things we find on such scans aren’t necessarily something we will do something about.”
New national guidelines for doctors already discourage scanning the brains of patients who complain of headache and migraine. But researchers found that the rate of brain scans for headache has risen, not fallen, since the guidelines came out.
“CTs and MRIs are commonly ordered for headache and migraine, and increasing over time, despite the fact that there are rare circumstances where imaging should be used,” said Callaghan.
“Lots of guidelines say we shouldn’t do this – including ones from neurology and radiology groups – but yet we still do it a lot. This is a source of tremendous cost in health care without a lot of evidence to justify the cost.”
A standard brain CT scan costs about $340, according to HealthCareBlueBook.com. One with a contrast agent to make a clearer image costs about $840. A standard brain MRI image costs about $660 and one with a contrast agent about $970. The costs don’t include charges for subsequent treatments that may be prompted by uncertain results.
The Choosing Wisely campaign, which encourages physicians to order fewer medical tests, says a brain scan “rarely shows why a headache occurs or helps you manage its symptoms.” Yet many doctors order them anyway, often feeling pressured by patients who fear they may have a brain tumor, aneurysm or some serious medical problem.
Only 1% to 3% of scans of patients with repeated headaches find that a tumor or blood vessel problem in the brain is to blame. And many of the problems that scans find often turn out not to pose a serious threat.
The UM researchers suggest that better education of the public and insurance plans that require patients to pay more of the cost may be needed to reduce the unnecessary use of brain scans.
“Doctors typically don’t consider costs, and patients usually aren’t paying directly for these scans,” Callaghan said. “Insurers may require prior authorizations but still cover the scans if they are ordered.”
In addition to the cost of unnecessary brain scans, the procedures may also expose patients to more risk.
“The financial costs of neuroimaging for headaches are substantial. But the costs we should care most about as physicians are the unnecessary radiation and incidental findings that lead to unnecessary medical procedures and great anxiety on the part of our patients,” said Michael H. Katz, MD, in an editorial also published in JAMA Internal Medicine.
“Because professional guidelines themselves appear to have limited impact on ordering of neuroimaging, we need to focus more on educating our patients about headaches and the dangers of neuroimaging.”
CT scans of the head can deliver a radiation dose equivalent to 25 to 300 chest X-rays, according to a recent study.
“While the risk from any single exposure is uncertain, the harmful effects of radiation may be cumulative, so it’s best to avoid it when you can,” the Choosing Wisely campaign advises doctors.
Brain scans should only be ordered if the headache is sudden or explosive, is different from other headaches the patient has had in the past, is brought on by exertion, or is accompanied by fever, seizure, vomiting, a loss of coordination, or a change in vision, speech, or alertness.