title: Headache neuroimaging: Routine testing when guidelines recommend against them.
abstract: OBJECTIVE
  The aim of this article is to determine the patient-level factors associated with headache neuroimaging in outpatient practice.
  
  
  METHODS
  Using data from the 2007-2010 National Ambulatory Medical Care Surveys (NAMCS), we estimated headache neuroimaging utilization (cross-sectional). Multivariable logistic regression was used to explore associations between patient-level factors and neuroimaging utilization. A Markov model with Monte Carlo simulation was used to estimate neuroimaging utilization over time at the individual patient level.
  
  
  RESULTS
  Migraine diagnoses (OR = 0.6, 95% CI 0.4-0.9) and chronic headaches (routine, chronic OR = 0.3, 95% CI 0.2-0.6; flare-up, chronic OR = 0.5, 95% CI 0.3-0.96) were associated with lower utilization, but even in these populations neuroimaging was ordered frequently. Red flags for intracranial pathology did not increase use of neuroimaging studies (OR = 1.4, 95% CI 0.95-2.2). Neurologist visits (OR = 1.7, 95% CI 0.99-2.9) and first visits to a practice (OR = 3.2, 95% CI 1.4-7.4) were associated with increased imaging. A patient with new migraine headaches has a 39% (95% CI 24-54%) chance of receiving a neuroimaging study after five years and a patient with a flare-up of chronic headaches has a 51% (32-68%) chance.
  
  
  CONCLUSIONS
  Neuroimaging is routinely ordered in outpatient headache patients including populations where guidelines specifically recommend against their use (migraines, chronic headaches, no red flags).
authors: University of Michigan, Ann Arbor, USA bcallagh@med.umich.edu.
authors: Brian C
authors: BC
authors: Callaghan
authors: University of Michigan, Ann Arbor, USA.
authors: Kevin A
authors: KA
authors: Kerber
authors: University of Michigan, Ann Arbor, USA.
authors: Robert J
authors: RJ
authors: Pace
authors: University of Michigan, Ann Arbor, USA.
authors: Lesli
authors: L
authors: Skolarus
authors: University of Michigan, Ann Arbor, USA.
authors: Wade
authors: W
authors: Cooper
authors: University of Michigan, Ann Arbor, USA VA Center for Clinical Management Research, USA.
authors: James F
authors: JF
authors: Burke
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D003430:Cross-Sectional Studies; D005260:Female; D006261:Headache / Q000175:diagnosis* / Q000453:epidemiology; D019538:Health Care Surveys / Q000379:methods / Q000592:standards*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009010:Monte Carlo Method; D059906:Neuroimaging / Q000379:methods / Q000592:standards*; D017410:Practice Guidelines as Topic / Q000592:standards*; D055815:Young Adult
keywords: Headaches; diagnostic testing; health care efficiencies; migraines