Migraine Expert Agrees Brain Scans Often Not Needed

Migraine Expert Agrees Brain Scans Often Not Needed

One of the nation’s leading experts on migraine headaches agrees that brain scans for headaches are often unnecessary.

Dr. Andrew Charles

Dr. Andrew Charles

Dr. Andrew Charles is the Director of the Headache Research and Treatment Program at UCLA.

He was responding to a new study published in JAMA Internal Medicine and reported here at the National Pain Report. Researchers found that in over 51 million headache related visits to physicians, one of our eight resulted in an MRI or CT Scan at the cost of $1 billion a year.

“This is an important study that provides strong evidence in support of what most neurologists and headache specialists already know: the majority of scans ordered for headache patients are unnecessary,” said Charles. “The reasons are complex and overlapping.”

Dr. Charles told us why he believes so many patients have unnecessary scans:

  1. Physicians commonly practice defensive medicine — they perceive that it is better to order a scan that they are confident will be normal rather than risk the extraordinarily small chance that it will abnormal and they might risk litigation.
  2. Patients have trouble believing that such severe pain and disability can be caused by something that doesn’t show up on a scan. They expect (and sometimes demand) that their physician will order a scan, and are not satisfied if it isn’t.
  3. In a small percentage of cases, physicians may have an incentive to order scans, because they have a financial relationship with the companies and individuals that do the scans and interpret them.
  4. It is much easier and less time consuming for a physician to simply order a scan than to take the time to explain to a patient that it is not necessary.

“In a world of limitless resources, this would all be fine — the scans aren’t known to be harmful (although some might argue with this, particularly for CT scans).  But resources are limited,” Charles said in an email to National Pain Report.

“Imagine if all of the money spent on unnecessary scans was instead spent on research to find better therapies for patients with headache, and on better care for the extraordinary number of patients with these disorders. We could be doing much better than we are now. This is an issue that patients and care providers need to tackle together.”

While new national guidelines for doctors already discourage scanning patients’ brains who complain of headache and migraine, researchers have found that the rate of brain scans for headaches has actually risen.

“The unfortunate reality is that with current imaging technologies, the overwhelming majority of patients with headache have no identifiable abnormality on CT or MRI scans. Perhaps in the future we will develop imaging approaches that will be better able to help us manage patients with headache, but we are simply not there yet,” Charles added.

Authored by: Ed Coghlan

There are 8 comments for this article
  1. Catherine Nichols Pogorzelski at 1:21 pm

    Trying to prove a patient’s health has deteriorated VIA the very tests designed to diagnose is a time consuming, painful and almost impossible taks, but I refuse to give up, having develeopd :systemic sclerosis/fibrosis” having no know KD (YET!) http://www.practical-patient-care.com/features/featurelingering-effects-gadolinium-based-contrast-agents-4187508/ from link, more there: This suggestion flies in the face of what is currently believed. In patients with normal renal function, gadolinium elimination is thought to be rapid and complete: toxic gadolinium ions are chemically bonded with non-metal ions (chelation) and quickly removed from the body. Pharmacokinetic studies suggest that over 90% of the substance is excreted in the first 12 hours.

  2. dave at 4:22 pm

    Dr. Rodrigues- I am in complete agreement with what you said.
    The irony, is that medicine today claims to be more patient oriented and more “personalized”(omics). And recently I read in hospitals doctors are penalized for visits lasting more than 8 minutes. The biggest complaint of patients today is lack of respect by doctors- so it is clear medicine today is medicocentric and not patient centered.

    The overemephasis today on evidenced- based technological one size fits all McDonaldization of medicine is not progress. In fact, increasingly we are seeing the erosion of reliability of research- as evidenced by Dr. Collins calling efforts at ensuring research reproducibility as “hobbled” or the innovation gap in new drug entities for pain- despite pain experts claiming much progress in understanding the pathophysiology of pain.

    The irony also, especially when it comes to opioids, is that long-term use of opioids for most conditions has not met the evidence pyramid standards- yet the U.S. consumes 80% of the worlds opioids- 230 million prescriptions for opioids were given in 2013.
    As the IOM report on pain care indicated we need a cultural change in pain care- but i don’t see evidence it is happening.

  3. Stephen S. Rodrigues, MD at 12:17 pm

    @dave, “Doctors have a choice to be more caring and less reductionistic”

    When I read textbooks from the 40s-80s I get a sense that those physicians were given some leeway to become and develop the art of medicine. To master medicine you have to think for freely and use your imagination, use the old ideas and new concepts, tries and failures to really get a feel for a disease and how a disease affect a person.

    Today if a patient’s problem do not fit into the box, the idea is to cut the person into segments to and fit in each segment into a few boxes. The old docs used to fashion a box for each case so the fit was custom made and personal. The former is science and the later is pseudoscience and as we know pseudoscience is not sanctioned by the AMA/DEA/Medicare and medical societies.

    The problems in medicine are all related to human nature, we want to easily twist physical, biological and emotional of sciences together into a mega-science and assuming that it’s as the reliable and infallible as the physical sciences. The belief that the “belief-in-science” will solve all diseases and belief that everyone who participates in science or medicine are all altruistic in their intent, motivations and beliefs.

  4. Dave at 1:42 pm

    Dr. Rodrigues- My previous post was regarding disagreeing with you the effectiveness of migraine and headache treatment. With regard to scans- I think it should be up to the “patient” to decide whether or not to be proactive.
    Doctors chose to be “regimented” and because of their reductionistic regimentation they miss much. Over 20% of the time their is misdiagnosis and 30% of symptoms are “medically unexplained”. And as I indicated before, too often headaches are misdiagnosed because doctors- especially neurologists- dont care much for people with headaches. And no wonder why 20% of all emergency room visits are from migraine alone. The reductionistic and quickie approach, coupled with the longstanding prejudice toward headaches has lead to the sorry state of affairs for people with headaches.
    Lastly, whether it is in FDA regulations, insurance requirements or what happens in the doctors office- this is mostly a function of what doctors want-and more importantly without much input from people in pain. Doctors have a choice to be more caring and less reductionistic- but unfortunately, as we well know they chose to be less than thorough, less than effective when it comes to pain.

  5. Stephen S. Rodrigues, MD at 12:59 pm

    @dave
    So you disagree with me.
    The need for scans? The idea of being proactive?
    The vast majority of cases scans are unnecessary. The clinical presentation history and physical determines that need. The issues most pressing that need to be found immediately are infections, tumors, aneurysmal lesions. So for a headache that has been in existence for months or years waxing and waning a scan will clarify the urgency but will add little to the treatment. Physicians will order a scan for security sakes and if a patient is really fearful but there is no scientific reasons to order them just a belief system. Emotional reasons are valid!

    The problem arises with a radiologist notes the “glitches,” and physicians and patients will obsess over these innocent anomalies or artifacts.

    The idea of being proactive? IMO, this is a major issue because MD’s are train to be very regimented from a short list or protocols that do NOT include alternatives. They are basically handicapped. People get frustrated when handicapped and that is what you perceive as uncaring.

    Being proactive, holistic and using alternatives are all we have on outside the box of scientific medicine. If you have a tumor — great today’s technology will save you. What if the scan is normal and you have tried all of the modern treatments without relief? Complementary and Alternative Medicine are the only other options.

  6. dave at 5:52 pm

    Dr. Rodrigues- I disagree. If headaches were treated effectively then cluster headaches and thunderclap headaches wouldn’t be referred to as “suicide headaches” The research is so clear about how poorly headaches are diagnosed and treated that even a NYS Senator- Senator Maziarz had legislation on orofacial pain acknowledging what I just said.
    Doctors are not proactive at managing headaches- they treat them with the usual prejudices and ignorance that is part and parcel of pain care. Furthermore, how many migrainuers receive a discussion about curative treatment like patent foramen ovale surgery? I know how bad headache treatment is because I have helped many to get their doctors to take their headaches more seriously. I shouldn’t have to be, in a sense, supervising doctors when it come to headaches- but because of their uncaring ways I am compelled to do so. And quite frankly, the headache treatment most people receive is careless and unprofessional- and when I get involved usually a client decides to change doctors and treatment changes dramatically.

  7. Stephen S. Rodrigues, MD at 4:07 pm

    This was actually discussed in a board review course in the late 90’s and I have utilized the concept since then. So we actually know this is happening and know that these scans are unnecessary.

    Why can’t leading physicians alter the course of these unnecessary studies? Because Dr. Charles has it correct!
    Also we do not offer patients, in pain, viable holistic therapeutic options anymore like many vetted alternatives.

    Do we really need images to manage headaches? No!
    As long as providers are proactive in the management of pain of all types. Within the management of pain the serious ones will be more obviously and the minor ones will be treated effectively and allowed to return to a normal healthy productive life.

  8. dave at 2:28 pm

    Dr Charles- we are all familiar with the received view. Nonetheless you fail to point out how poorly funded migraine research is at NIH- so assuming you and your concerned colleagues in medicine are advocating for funding better assessment research- it hasn’t been happening. In fact in the book: A Brain Wider than the Sky- Mr Levy points out that asthma receives several times the funding at NIH than migraines do. So even if neurologists are making a serious effort to call for more migraine research at NIH- and there are certainly neurologists in more than a few advisory committees at NIH- they are not “pressing on the mark” and it is a red herring to suggest all the money that neurologists save by not doing scans would be sent without delay to research at NIH or anywhere else.

    You fail to mention how poorly doctors do in diagnosing migraine of that migraines can and do lead to stroke-and needless to say you fail to mention the angiomas that may present as migraine. Do you and your colleagues use the AMAS test when a client comes in complaining of migraine like symptoms? Or do doctors take the risk for them that it is probably not cancer? And revert to old fashioned bedside diagnosis that betrays the laboratory medicine of the 20th century?

    Your fourth point is revealing. Yes it is about time- for scans take time to do and interpret and report back to people with headaches- it is more convenient to tell a person with headaches to be a good patient and that it probably isn’t serious, prescribe standard preparations like a triptan and then focus on the next patient. In this forum, we know most doctors “don’t have time for the pain”
    Lastly- you seem to maintain the convenient paternalism of medicine rather than shared decision making and “patient activation”. You seem to forget that migraineurs have right dorsolateral prefrontal cortex, a righ temporoparietal unction just as the have region 24a in their mediocingulate cortex and they are not merely objects, but thinking and suffering person-not to be subugated to suboptimal Cnidian antipathic medicocentric parlous pain care . In other words let them decide if they want a scan or not for your arguments are less than thoroughgoing and even if no migraineur ever received a scan again that would not lead to better assessment or treatment of migraines-after all it is their life and not yours to do as you please.