Clinicians are not heeding recommendations to counsel patients with headache to make lifestyle changes, according to a study published online ahead of print January 8 in the Journal of General Internal Medicine.


Lead author John N. Mafi, MD, and colleagues analyzed an estimated 144 million patient visits between 1999 and 2010 and found low-value, high-cost services, such as advanced imaging and prescriptions of opioids and barbiturates, were overused.

Advanced imaging, such as computed tomography and magnetic resonance imaging, increased significantly from 6.7% of visits in 1999 to 13.9% in 2010. In contrast, the study found that counseling by clinicians decreased from 23.5% to 18.5% between 1999 and 2010.


“Despite the publication of numerous practice guidelines, clinicians are increasingly ordering advanced imaging and referring to specialists while less frequently suggesting first-line lifestyle modifications to their patients,” said Mafi.


Use of acetaminophen and nonsteroidal anti-inflammatory drugs remained stable at approximately 16% of the medications used during the study period, whereas the use of anti-migraine medications such as triptans and ergot alkaloids increased from 9.8% to 15.4%.

Preventive therapies, including anticonvulsants, antidepressants, beta blockers, and calcium-channel blockers, that are recommended by guidelines increased from 8.5% to 15.9%. The researchers found no increase in the use of opioids or barbiturates, which is discouraged, although they were used in 18% of the cases reviewed.


“Clinicians are increasingly ordering advanced imaging and referring to other physicians, and less frequently offering lifestyle counseling to their patients,” said Dr. Mafi. “The management of headache represents an important opportunity to improve the value of U.S. health care.”