1. Don’t perform neuroimaging studies in patients with stable headaches that meet criteria for migraine.
- At least 5 attacks fulfilling criteria B-D
- Headache attacks lasting 4-72 hours (untreated or unsuccessfully treated)
- Headache has at least two of the following characteristics:
- unilateral location
- pulsating quality
- moderate or severe pain intensity
- aggravation by or causing avoidance of routine physical activity (eg, walking or climbing stairs)
- During headache at least one of the following:
- nausea and/or vomiting
- photophobia and phonophobia
- Not attributed to another disorder
2. Don’t perform CT imaging for headache when MRI is available, except in emergency settings.
CT is indicated in emergency settings when hemorrhage, acute stroke, or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions, and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure that may elevate the risk of later cancers, while there are no known biologic risks from MRI.
Patients may ask you about this:
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.
4. Don’t prescribe opioid or butalbital-containing medications as first-line treatment for recurrent headache disorders.
These medications impair alertness and may produce dependence or addiction syndromes, an undesirable risk for the young, otherwise healthy people most likely to have recurrent headaches.
5. Don’t recommend prolonged or frequent use of over-the-counter (OTC) pain medications for headache.
OTC medications are appropriate treatment for occasional headaches if they work reliably without intolerable side effects. Frequent use (especially of caffeine-containing medications) can lead to an increase in headaches, resulting in “medication overuse headache” (MOH). To avoid this, OTC medication should be limited to no more than 2 days per week.