Choosing Wisely in Headache Medicine: The <scp>A</scp>merican Headache Society's List of Five Things Physicians and Patients Should Question

Loder, Elizabeth; Weizenbaum, Emma; Frishberg, Benjamin; Silberstein, Stephen D.

doi:10.1111/head.12233

Cited by 163 publications

(116 citation statements)

References 22 publications

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“…The diagnosis and pathophysiologic mechanism of pain have implications for symptomatic pain treatment with medication. For example, evidence is limited or insufficient for improved pain or function with long-term use of opioids for several chronic pain conditions for which opioids are commonly prescribed, such as low back pain (182), headache (183), and fibromyalgia (184). Although NSAIDs can be used for exacerbations of nociceptive pain, other medications (e.g., tricyclics, selected anticonvulsants, or transdermal lidocaine) generally are recommended for neuropathic pain.…”

Section: Evidence Typementioning

confidence: 99%

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Haegerich²,

2016

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Section: Evidence Typementioning

confidence: 99%

CDC Guideline for Prescribing Opioids for Chronic Pain — United States, 2016

Haegerich²,

2016

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“…Recently, Choosing Wisely guidelines have focused on overuse by questioning the use of diagnostic neuroimaging in 2 highly prevalent neurologic conditions: headache and peripheral neuropathy. 2,3 Guideline discordant neuroimaging overuse appears to be common for headache 4,5 and peripheral neuropathy. [6][7][8] At the same time, underuse of neuroimaging in some highrisk headache patients 9 and diagnostic laboratory testing 10 in neuropathy patients likely exists.…”

mentioning

confidence: 99%

Neuroimaging overuse is more common in Medicare compared with the VA

et al. 2016

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Objective: To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.Methods: Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n 5 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n 5 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.Results: For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p , 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p , 0.001), and the difference persisted after excluding nontarget conditions. Conclusions:Overuse of neuroimaging is likely less common in the VA than in a Medicare population.Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing. Neurology ® 2016;87:792-798 GLOSSARY HRS 5 Health and Retirement Study; ICD-9 5 International Classification of Diseases-9; NCS 5 nerve conduction studies; SPEP 5 serum protein electrophoresis; VA 5 Veterans Affairs.

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“…This was contrary to the guidelines originally laid down by Frishberg, [2] and later confirmed in a number of studies. [3,4] These guidelines suggested that for migraines, there was no difference in the incidence of clinically meaningful pathology to the incidence in the general population, and that neuroimaging is unnecessary. [5] Exceptions to these recommendations are the presence of the following red flags:…”

Section: Neuroimaging In Migrainementioning

confidence: 99%