The American Board of Internal Medicine (ABIM) Foundation launched a campaign in 2012 called “Choosing Wisely.” The goal was to talk about medical care that might not be necessary, or may even be detrimental. Dr. Christine Cassel the head of the ABIM Foundation said submitted lists from physician specialty societies were “intended to start a national conversation about eliminating waste and unnecessary tests and procedures that don’t benefit the patient and can cause harm.”

Eight headache specialists were appointed by the American Headache Society (AHS) who reached a consensus regarding five situations commonly found in headache medicine that were linked with poor patient outcomes, low value care, and documented overuse or misuse of resources. These recommendations were submitted to the ABIM Foundation; they were unanimously approved.

The American Headache Society “Choosing Wisely” Recommendations:

1.  Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.

2.  Don’t perform CT imaging for headache when MRI is available, except in emergency settings. When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage , acute stroke or head trauma are suspected.

3.  Don’t recommend surgical deactivation of migraine trigger points outside of a clinical trial. The value of this form of “migraine surgery” is still a research question. Large, randomized controlled trials with long-term follow-up are needed to provide accurate estimates of the effectiveness and harms of surgery.

4.  Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders. This recommendation is not meant to imply that opioid or butalbital medications are always inappropriate treatments for recurrent headache treatments. It is meant to address the appropriate order in which medication classes should typically be used. The committee felt there is strong evidence that these medications should be avoided as first-line treatment in all recurrent headache disorders, not just migraine.

5.  Don’t recommend prolonged or frequent use of over-the-counter pain medications for headache.  OTC medications are appropriate for occasional headaches if they work without uncomfortable side effects. Frequent use (particularly of caffeine-containing medications) can lead to an increase in headaches – resulting in “medication overuse headache” (MOH). OTC medications should be limited to no more than 2 days per week. In addition to MOH, prolonged use of acetaminophen can cause liver damage, while overusing nonsteroidal anti-inflammatory drugs may lead to gastrointestinal bleeding.

Members of the American Headache Society Choosing Wisely Task Force: Elizabeth Loder, AHS President, Chair; Stephen Silberstein, Chair of the Guidelines and Position Statements Committee; Benjamin Frishberg; Randolph W. Evans; Scott Litin, Josef Stakic, Donald Dworek; Jessica Ailani.     Headache: The Journal of Head and Face Pain       November/December   2013





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