Headache neuroimaging: Routine testing when guidelines recommend against them

Cephalalgia. 2015 Nov;35(13):1144-52. doi: 10.1177/0333102415572918. Epub 2015 Feb 12.


Aims: The aim of this article is to determine the patient-level factors associated with headache neuroimaging in outpatient practice.

Methods: Using data from the 2007-2010 National Ambulatory Medical Care Surveys (NAMCS), we estimated headache neuroimaging utilization (cross-sectional). Multivariable logistic regression was used to explore associations between patient-level factors and neuroimaging utilization. A Markov model with Monte Carlo simulation was used to estimate neuroimaging utilization over time at the individual patient level.

Results: Migraine diagnoses (OR = 0.6, 95% CI 0.4-0.9) and chronic headaches (routine, chronic OR = 0.3, 95% CI 0.2-0.6; flare-up, chronic OR = 0.5, 95% CI 0.3-0.96) were associated with lower utilization, but even in these populations neuroimaging was ordered frequently. Red flags for intracranial pathology did not increase use of neuroimaging studies (OR = 1.4, 95% CI 0.95-2.2). Neurologist visits (OR = 1.7, 95% CI 0.99-2.9) and first visits to a practice (OR = 3.2, 95% CI 1.4-7.4) were associated with increased imaging. A patient with new migraine headaches has a 39% (95% CI 24-54%) chance of receiving a neuroimaging study after five years and a patient with a flare-up of chronic headaches has a 51% (32-68%) chance.

Conclusions: Neuroimaging is routinely ordered in outpatient headache patients including populations where guidelines specifically recommend against their use (migraines, chronic headaches, no red flags).

Keywords: Headaches; diagnostic testing; health care efficiencies; migraines.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Cross-Sectional Studies
  • Female
  • Headache / diagnosis*
  • Headache / epidemiology
  • Health Care Surveys / methods
  • Health Care Surveys / standards*
  • Humans
  • Male
  • Middle Aged
  • Monte Carlo Method
  • Neuroimaging / methods
  • Neuroimaging / standards*
  • Practice Guidelines as Topic / standards*
  • Young Adult