Many patients with brain tumors present with isolated headaches but no other symptoms. Use neuroimaging to help the diagnosis, or cut costs?
Reducing neuroimaging tests for patients with headaches runs the risk of missing or delaying the diagnosis of brain tumors, according to a new study.
“Patients with brain tumors may present with isolated headaches in the absence of other neurological symptoms and signs. Early diagnosis of brain tumors allows prompt treatment before more severe symptoms, reduced performance status, and worsened outcomes,” stated the researchers, led by neurosurgeon Ammar H. Hawasli, MD, from Washington University School of Medicine, St Louis.
“As physicians grapple with the difficult conflict between evidence-based cost-cutting guidelines and individualized patient-tailored medicine, they must carefully balance the costs and benefits of discretionary services, such as neuroimaging for headaches.”
Despite recently published guidelines to limit neuroimaging for headache, there has been a progressive increase in neuroimaging for headaches in the United States. In most cases, diagnosis of migraine and other types of headache can be made in the doctor’s office, without any special tests. “Nonetheless, neuroimaging in the United States between 2007 and 2010 for migraines and headaches approached $1.2 billion,” the researchers stated.
“Medical providers have likely continued high use of neuroimaging for headaches because of concerns about potential missed diagnoses and medical errors, which would adversely affect patient outcomes and, in turn, affect malpractice liability,” they said.
The recent guidelines seek to reduce the use of neuroimaging for patients with headaches to limit the use of unnecessary and costly medical tests. For example, the “Choosing Wisely” guidelines developed by the American College of Radiology and Consumer Reports include the recommendation, “Don’t do imaging for uncomplicated headaches.”
"Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor," the investigators stated. "Specifically, patients with brain tumors may present with isolated headaches in the absence of other neurological symptoms and signs.”
The researchers presented their analysis of a series of 95 patients with a confirmed diagnosis of brain tumor. Nearly half of the patients had a combination of symptoms, such as seizures, cognitive and speech dysfunction, and other neurological abnormalities. However, about one-fourth of the patients had isolated headaches, no symptoms, or nonspecific symptoms.
In 11 patients, headache was the only symptom of brain tumor; 4 of these patients had new-onset headaches that would have qualified them for neuroimaging under recently proposed guidelines. The other 7 patients had migraine or other types of headache and would not have been chosen for neuroimaging.
Depending on which set of recent recommendations had been followed, neuroimaging would have been delayed or never performed in 3% to 7% of patients who had brain tumors.
“We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system,” the researchers concluded. “Although we do not recommend routine screening for the general population, we do contend that a substantial number of patients with brain tumors will present with isolated headaches.”
The researchers published their results in the January 2015 issue of Neurosurgery.