Should Neurologists Request Imaging for Uncomplicated Headache?

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb