Choosing Wisely in Headache Treatment–Things Patients Should Question According to Headache Specialists

Choosing Wisely in Medical Care

The American Board of Internal Medicine Foundation started a program looking for things in each branch of medicine that was, based on clinical trials, had no or little value in helping patients get better. The goal was to identify five things that patients should question as part of their care. In 2013 the American Headache Society interviewed, via e-mail and sometimes phone follow up their members (all headache specialists), for their recommendations for this list of “Choosing Wisely.” Here were the top eleven things that have very little evidence of helping patients get better based on decades of research. Only the top five (highlighted) were submitted to the final list.

  1. Overusing imaging (MRI, CT scans, Neck X rays, Neck MRIs). These things almost never help the patient and cost lots of money.
  2. Overuse of opioids. Opioids only have a very limited role in headache management and their over-use is one of the most common reasons headaches spiral out of control (Medication Overuse Headaches).
  3. Overuse of butalbital-containing compounds (same reason as # 2).
  4. Overuse of EEGs to diagnose or treat headaches.
  5. Under dosing or limiting the use of triptans.
  6. Overuse of caffeine-containing medications.
  7. Overuse of surgery for headaches including rhizotomy, occipital nerve surgery, sinus surgery or surgery for Chiari malformations.
  8. Overuse of facet join (neck) injections and radiofrequency procedures for headaches.
  9. Misuse of botulinum toxin (Botox) for episodic migraine and non-migraine headaches.
  10. Overuse of dietary manipulation, allergy testing, homeopathy, craniosacral therapy, or chiropractic treatment.
  11. Using bio-identical hormone treatment for menstrual migraine.

From Choosing Wisely in Headache Medicine: The American Headache Society’s List of Five Things Physicians and Patients Should Question (Journal of Headache 2013;52:1651-1659).