Neuroimaging in headache: Fewer flags may improve care
James C.Johnston, Neurologist, GlobalNeurology
Submitted January 21, 2019
The article by Do et al.1 on secondary headaches is particularly relevant since headache misdiagnosis consistently remains among the most common diagnostic errors in neurology.2 However, the literature must be carefully scrutinized to avoid distorting the use of red flags and, thereby, perpetuating headache mismanagement. For example, Do et al. cited the Birmingham Study describing significant intracranial abnormalities in 2.1% of 530 patients as partial evidence for advancing flags.3 But the Birmingham Study—characterized by limited demographics, patient selection variability, and suboptimal imaging—excluded patients with abnormal imaging arbitrarily labeled insignificant, including, for example, small arachnoid cysts, despite there being no correlations between preoperative cyst volume and headache, or between postoperative reduction and clinical improvement.4 Moreover, Johnston et al.5 noted the study was “rendered meaningless by the lack of follow up to determine whether the [85.5% of] patients not imaged were subsequently found to have an intracranial abnormality.”
Neuroimaging protocols should be prudently refined through well-designed prospective studies focused on improving patient care, recognizing that a reduction of imaging through additional flags may not translate to decreased healthcare expenditure considering the enormous costs associated with headache misdiagnosis, including unnecessary medical expenses, loss of patient productivity, liability expenses, and related factors balanced against an MRI fee.5
References
Do TP, Remmers A, Schytz HW, et al. Red and orange flags for secondary headaches in clinical practice: SNNOOP10 list. Neurology 2019;92:134–144.
Physician Insurers Association of America. Risk Management Review (Neurology). Rockville, MD: PIAA; 2016.
Clarke CE, Edwards J, Nicholl DJ, Sivaguru A. Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service. J Neurol 2010;257:1274–1278.
Mørkve SH, Helland CA, Amus J, Lund-Johansen M, Wester KG. Surgical Decompression of Arachnoid Cysts Leads to Improved Quality of Life: A Prospective Study. Neurosurgery 2016; 78:613–625.
Johnston JC, Wester K, Sartwelle TP. Neurological Fallacies Leading to Malpractice: A Case Studies Approach. Neurol Clin 2016;34:747–773.
The article by Do et al.1 on secondary headaches is particularly relevant since headache misdiagnosis consistently remains among the most common diagnostic errors in neurology.2 However, the literature must be carefully scrutinized to avoid distorting the use of red flags and, thereby, perpetuating headache mismanagement. For example, Do et al. cited the Birmingham Study describing significant intracranial abnormalities in 2.1% of 530 patients as partial evidence for advancing flags.3 But the Birmingham Study—characterized by limited demographics, patient selection variability, and suboptimal imaging—excluded patients with abnormal imaging arbitrarily labeled insignificant, including, for example, small arachnoid cysts, despite there being no correlations between preoperative cyst volume and headache, or between postoperative reduction and clinical improvement.4 Moreover, Johnston et al.5 noted the study was “rendered meaningless by the lack of follow up to determine whether the [85.5% of] patients not imaged were subsequently found to have an intracranial abnormality.”
Neuroimaging protocols should be prudently refined through well-designed prospective studies focused on improving patient care, recognizing that a reduction of imaging through additional flags may not translate to decreased healthcare expenditure considering the enormous costs associated with headache misdiagnosis, including unnecessary medical expenses, loss of patient productivity, liability expenses, and related factors balanced against an MRI fee.5
References
Footnotes
For disclosures, please contact the editorial office at journal@neurology.org.