The Quality of Headache Treatment in The United States: Review and Analysis of Recent Data

Neuroimaging overuse is more common in Medicare compared with the VA

OBJECTIVE

To inform initiatives to reduce overuse, we compared neuroimaging appropriateness in a large Medicare cohort with a Department of Veterans Affairs (VA) cohort.

METHODS

Separate retrospective cohorts were established in Medicare and in VA for headache and neuropathy from 2004 to 2011. The Medicare cohorts included all patients enrolled in the Health and Retirement Study (HRS) with linked Medicare claims (HRS-Medicare; n = 1,244 for headache and 998 for neuropathy). The VA cohorts included all patients receiving services in the VA (n = 93,755 for headache and 183,642 for neuropathy). Inclusion criteria were age over 65 years and an outpatient visit for incident neuropathy or a primary headache. Neuroimaging use was measured with Current Procedural Terminology codes and potential overuse was defined using published criteria for use with administrative data. Increasingly specific appropriateness criteria excluded nontarget conditions for which neuroimaging may be appropriate.

RESULTS

For both peripheral neuropathy and headache, potentially inappropriate imaging was more common in HRS-Medicare compared with the VA. Forty-nine percentage of all headache patients received neuroimaging in HRS-Medicare compared with 22.1% in the VA (p < 0.001) and differences persist when analyzing more specific definitions of overuse. A total of 23.7% of all HRS-Medicare incident neuropathy patients received neuroimaging compared with 9.0% in the VA (p < 0.001), and the difference persisted after excluding nontarget conditions.

CONCLUSIONS

Overuse of neuroimaging is likely less common in the VA than in a Medicare population. Better understanding the reasons for the more selective use of neuroimaging in the VA could help inform future initiatives to reduce overuse of diagnostic testing.

A double-blind placebo-controlled pilot study of sublingual feverfew and ginger (LipiGesic™ M) in the treatment of migraine

BACKGROUND

Therapeutic needs of migraineurs vary considerably from patient to patient and even attack to attack. Some attacks require high-end therapy, while other attacks have treatment needs that are less immediate. While triptans are considered the "gold standard" of migraine therapy, they do have limitations and many patients are seeking other therapeutic alternatives. In 2005, an open-label study of feverfew/ginger suggested efficacy for attacks of migraine treated early during the mild headache phase of the attack.

METHODS/MATERIALS

In this multi-center pilot study, 60 patients treated 221 attacks of migraine with sublingual feverfew/ginger or placebo. All subjects met International Headache Society criteria for migraine with or without aura, experiencing 2-6 attacks of migraine per month within the previous 3 months. Subjects had <15 headache days per month and were not experiencing medication overuse headache. Inclusion required that subjects were able to identify a period of mild headache in at least 75% of attacks. Subjects were required to be able to distinguish migraine from non-migraine headache. Subjects were randomized 3:1 to receive either sublingual feverfew/ginger or a matching placebo and were instructed but not required to treat with study medication at the earliest recognition of migraine.

RESULTS

Sixty subjects treated 208 evaluable attacks of migraine over a 1-month period; 45 subjects treated 163 attacks with sublingual feverfew/ginger and 15 subjects treated 58 attacks with a sublingual placebo preparation. Evaluable diaries were completed for 151 attacks of migraine in the population using feverfew/ginger and 57 attacks for those attacks treated with placebo. At 2 hours, 32% of subjects receiving active medication and 16% of subjects receiving placebo were pain-free (P= .02). At 2 hours, 63% of subjects receiving feverfew/ginger found pain relief (pain-free or mild headache) vs 39% for placebo (P= .002). Pain level differences on a 4-point pain scale for those receiving feverfew/ginger vs placebo were -0.24 vs -0.04 respectively (P= .006). Feverfew/ginger was generally well tolerated with oral numbness and nausea being the most frequently occurring adverse event.

CONCLUSION

Sublingual feverfew/ginger appears safe and effective as a first-line abortive treatment for a population of migraineurs who frequently experience mild headache prior to the onset of moderate to severe headache.

Developing a research agenda in headache service delivery: proceed with caution

With a recognition that the management of headache remains far from ideal, there may be more immediate potential to reduce the burden of illness from developments in the delivery of headache services. There is a paucity of evidence in this area and a danger that an expanding research agenda will be dominated by inappropriate methodological frameworks that have been so successful in developing medical treatments. The prevailing scientific methods are underpinned by statistical approaches that are aggregative in nature and assume independence of system elements, an approach that may have limited utility in the analysis of complex systems such as headache care delivery. This review calls for a shift in headache research resources to organizational development and briefly outlines alternative methodological considerations.

Biomarkers in migraine: their promise, problems, and practical applications

Biomarkers are physical signs or laboratory measurements that "occur in association with a pathological process and have putative diagnostic and/or prognostic utility." Biomarkers hold considerable promise for understanding and intervening in the disease process of migraine. They may permit recognition of individuals at risk of developing migraine, improve the timing, accuracy, and precision of migraine diagnosis, and serve as indicators of treatment response and disease progression. Furthermore, they hold great promise for research. At the same time, there are important limitations to the use of biomarkers in migraine, including problems with validity, reliability, accuracy, and precision. Legal, ethical, and cost considerations are also important. This review describes the potential uses and limitations of biomarkers in migraine diagnosis, treatment, and research.