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J Gen Intern Med. 2015 May;30(5):548-55. doi: 10.1007/s11606-014-3107-3. Epub 2015 Jan 8.

Trends in the ambulatory management of headache: analysis of NAMCS and NHAMCS data 1999-2010.

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Division of General Medicine and Primary Care, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, CO-1309, Boston, MA, 02215, USA,



Headache is a frequent complaint and among the most common reasons for visiting a physician.


To characterize trends from 1999 through 2010 in the management of headache.


Longitudinal trends analysis.


Nationally representative sample of visits to clinicians for headache from the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey, excluding visits with "red flags," such as neurologic deficit, cancer, or trauma.


Use of advanced imaging (CT/MRI), opioids/barbiturates, and referrals to other physicians (guideline-discordant indicators), as well as counseling on lifestyle modifications and use of preventive medications including verapamil, topiramate, amitriptyline, or propranolol (guideline-concordant during study period). We analyzed results using logistic regression, adjusting for patient and clinician characteristics, and weighted to reflect U.S. population estimates. Additionally, we stratified findings based on migraine versus non-migraine, acute versus chronic symptoms, and whether the clinician self-identified as the primary care physician.


We identified 9,362 visits for headache, representing an estimated 144 million visits during the study period. Nearly three-quarters of patients were female, and the mean age was approximately 46 years. Use of CT/MRI rose from 6.7% of visits in 1999-2000 to 13.9% in 2009-2010 (unadjusted p < 0.001), and referrals to other physicians increased from 6.9 % to 13.2% (p = 0.005). In contrast, clinician counseling declined from 23.5 % to 18.5% (p = 0.041). Use of preventive medications increased from 8.5 % to 15.9% (p = 0.001), while opioids/barbiturates remained unchanged, at approximately 18%. Adjusted trends were similar, as were results after stratifying by migraine versus non-migraine and acute versus chronic presentation. Primary care clinicians had lower odds of ordering CT/MRI (OR 0.56 [0.42, 0.74]).


Contrary to numerous guidelines, clinicians are increasingly ordering advanced imaging and referring to other physicians, and less frequently offering lifestyle counseling to their patients. The management of headache represents an important opportunity to improve the value of U.S. healthcare.

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