COMMENTARY—A Detailed History and a Neurologic Exam Often Suffice

Everyone agrees that health care costs are much too high in the United States and that we should try to save money without harming our patients. Many headache specialists also agree that although we never want to miss a brain tumor, the chance of finding one in a patient with long-term, stable headache syndromes is small. Headache diagnoses are most reliably made through a detailed history taken carefully by a knowledgeable doctor who has enough time. If a patient has no red flags that suggest a secondary cause of headache, if his or her headache fits the established diagnostic criteria, and his or her physical and neurologic examinations are normal, then the patient most probably does not have a brain tumor.

But could a physician miss a brain tumor by not ordering an MRI? Yes, it is possible, but unlikely. What would the consequences be? According to the article by Hawasli and colleagues, a missed brain tumor will result in the delay of diagnosis, worse outcome, and probable legal consequences that entail great cost. The scare of legal consequences is a big part of the problem. Another few months of not knowing about a brain tumor are rarely problematic. If the tumor is a benign meningioma on the surface of the brain, then waiting a year or more to know should not be a problem. If it is a grade IV glioblastoma or metastatic tumor to the brain, it might be good to treat the patient sooner, but the eventual outcome probably would be no different.

If a patient comes to me with recent headaches or a history suggesting a problem with brain function, I need to perform an MRI scan and other testing to rule out brain tumor and other causes of brain dysfunction. If another patient comes to me with a 15-year history of headache that fits the criteria for migraine and has not been well treated, I prefer to treat him or her and not perform an extensive workup. I tell him or her that I cannot be sure what I might find if I performed a scan, but I would to try to help them improve first. If they do improve, they do not need a scan, let alone a second or third scan. More doctors would practice this way if they had less chance of being sued because the diagnosis was delayed by two months.

More than 90% of the patients with brain tumors that I have seen had migraine or another primary headache and an incidental, benign tumor that did not require surgery. If I had not performed an MRI, I could have been sued when the patient found out about the tumor, even if it was not the cause of the headache. With tort reform, everyone would be better off.

Therefore, I support the American Headache Society’s recommendations authored by Dr. Loder, as well as the American College of Radiology’s recommendations. A careful, detailed history and a complete neurologic exam are imperative to determine whether further testing is required. If the doctor does not have the time or expertise to do these things, then the patient should be referred to an expert.

—Alan M. Rapoport, MD
Clinical Professor of Neurology
The David Geffen School of Medicine at UCLA
President of the International Headache Society

Everyone agrees that health care costs are much too high in the United States and that we should try to save money without harming our patients. Many headache specialists also agree that although we never want to miss a brain tumor, the chance of finding one in a patient with long-term, stable headache syndromes is small. Headache diagnoses are most reliably made through a detailed history taken carefully by a knowledgeable doctor who has enough time. If a patient has no red flags that suggest a secondary cause of headache, if his or her headache fits the established diagnostic criteria, and his or her physical and neurologic examinations are normal, then the patient most probably does not have a brain tumor.

But could a physician miss a brain tumor by not ordering an MRI? Yes, it is possible, but unlikely. What would the consequences be? According to the article by Hawasli and colleagues, a missed brain tumor will result in the delay of diagnosis, worse outcome, and probable legal consequences that entail great cost. The scare of legal consequences is a big part of the problem. Another few months of not knowing about a brain tumor are rarely problematic. If the tumor is a benign meningioma on the surface of the brain, then waiting a year or more to know should not be a problem. If it is a grade IV glioblastoma or metastatic tumor to the brain, it might be good to treat the patient sooner, but the eventual outcome probably would be no different.

If a patient comes to me with recent headaches or a history suggesting a problem with brain function, I need to perform an MRI scan and other testing to rule out brain tumor and other causes of brain dysfunction. If another patient comes to me with a 15-year history of headache that fits the criteria for migraine and has not been well treated, I prefer to treat him or her and not perform an extensive workup. I tell him or her that I cannot be sure what I might find if I performed a scan, but I would to try to help them improve first. If they do improve, they do not need a scan, let alone a second or third scan. More doctors would practice this way if they had less chance of being sued because the diagnosis was delayed by two months.

More than 90% of the patients with brain tumors that I have seen had migraine or another primary headache and an incidental, benign tumor that did not require surgery. If I had not performed an MRI, I could have been sued when the patient found out about the tumor, even if it was not the cause of the headache. With tort reform, everyone would be better off.

Therefore, I support the American Headache Society’s recommendations authored by Dr. Loder, as well as the American College of Radiology’s recommendations. A careful, detailed history and a complete neurologic exam are imperative to determine whether further testing is required. If the doctor does not have the time or expertise to do these things, then the patient should be referred to an expert.

—Alan M. Rapoport, MD
Clinical Professor of Neurology
The David Geffen School of Medicine at UCLA
President of the International Headache Society

Everyone agrees that health care costs are much too high in the United States and that we should try to save money without harming our patients. Many headache specialists also agree that although we never want to miss a brain tumor, the chance of finding one in a patient with long-term, stable headache syndromes is small. Headache diagnoses are most reliably made through a detailed history taken carefully by a knowledgeable doctor who has enough time. If a patient has no red flags that suggest a secondary cause of headache, if his or her headache fits the established diagnostic criteria, and his or her physical and neurologic examinations are normal, then the patient most probably does not have a brain tumor.

But could a physician miss a brain tumor by not ordering an MRI? Yes, it is possible, but unlikely. What would the consequences be? According to the article by Hawasli and colleagues, a missed brain tumor will result in the delay of diagnosis, worse outcome, and probable legal consequences that entail great cost. The scare of legal consequences is a big part of the problem. Another few months of not knowing about a brain tumor are rarely problematic. If the tumor is a benign meningioma on the surface of the brain, then waiting a year or more to know should not be a problem. If it is a grade IV glioblastoma or metastatic tumor to the brain, it might be good to treat the patient sooner, but the eventual outcome probably would be no different.

If a patient comes to me with recent headaches or a history suggesting a problem with brain function, I need to perform an MRI scan and other testing to rule out brain tumor and other causes of brain dysfunction. If another patient comes to me with a 15-year history of headache that fits the criteria for migraine and has not been well treated, I prefer to treat him or her and not perform an extensive workup. I tell him or her that I cannot be sure what I might find if I performed a scan, but I would to try to help them improve first. If they do improve, they do not need a scan, let alone a second or third scan. More doctors would practice this way if they had less chance of being sued because the diagnosis was delayed by two months.

More than 90% of the patients with brain tumors that I have seen had migraine or another primary headache and an incidental, benign tumor that did not require surgery. If I had not performed an MRI, I could have been sued when the patient found out about the tumor, even if it was not the cause of the headache. With tort reform, everyone would be better off.

Therefore, I support the American Headache Society’s recommendations authored by Dr. Loder, as well as the American College of Radiology’s recommendations. A careful, detailed history and a complete neurologic exam are imperative to determine whether further testing is required. If the doctor does not have the time or expertise to do these things, then the patient should be referred to an expert.

—Alan M. Rapoport, MD
Clinical Professor of Neurology
The David Geffen School of Medicine at UCLA
President of the International Headache Society