Literature Review

Exercise may help patients with Parkinson’s disease improve their balance, ability to move around, and quality of life, even if it does not reduce their risk of falling, according to a new study published online ahead of print December 31, 2014, in Neurology.

Falling is common among people with Parkinson’s disease. Approximately 60% of patients fall each year, and two-thirds of these individuals fall repeatedly. “The resulting injuries, pain, limitations of activity, and fear of falling again can really affect people’s health and well-being,” said study author Colleen G. Canning, PhD, Associate Professor of Physiotherapy at the University of Sydney.

Evidence from systematic reviews shows that exercise programs are effective in preventing falls in the general older population, so Dr. Canning and colleagues sought to determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, including poor balance, reduced leg muscle strength, and freezing of gait, in patients with Parkinson’s disease.

For the study, 231 patients with Parkinson’s disease received their usual care or took part in an exercise program three times per week for six months. Each session consisted of 40 to 60 minutes of balance and leg-strengthening exercises. This minimally supervised exercise program was prescribed and monitored by a physical therapist, and participants performed most of the exercise at home. On average, 13% of the exercise sessions were supervised by a physical therapist.

Six months of falls data were available for 225 study participants, and one or more months of falls data were available for the remaining six participants. During the intervention period, 467 falls (4.1 per person) were reported in the exercise group, and 810 falls (7.0 per person) were reported in the control group. This difference in fall rate was not statistically significant.

Prespecified subgroup analysis, however, did reveal a significant interaction effect for disease severity. The number of falls by participants who exercised was reduced among people with less severe Parkinson’s disease, but not in those with more severe disease, compared with the number of falls for the control group. For participants with less severe disease, a 69% reduction in falls was reported in people who exercised, compared with those who did not.

“These results suggest that minimally supervised exercise programs aimed at reducing falls in people with Parkinson’s disease should be started early in the disease process,” Dr. Canning said. Because the progression of disease affects both motor and nonmotor systems, patients with more severe disease may derive more benefit from a multifactorial, closely supervised intervention, the researchers suggested. Overall, patients who took part in the exercise program performed better on tests of ability to move around and balance, had a lower fear of falls, and reported better overall mood and quality of life.

Exercise may help patients with Parkinson’s disease improve their balance, ability to move around, and quality of life, even if it does not reduce their risk of falling, according to a new study published online ahead of print December 31, 2014, in Neurology.

Falling is common among people with Parkinson’s disease. Approximately 60% of patients fall each year, and two-thirds of these individuals fall repeatedly. “The resulting injuries, pain, limitations of activity, and fear of falling again can really affect people’s health and well-being,” said study author Colleen G. Canning, PhD, Associate Professor of Physiotherapy at the University of Sydney.

Evidence from systematic reviews shows that exercise programs are effective in preventing falls in the general older population, so Dr. Canning and colleagues sought to determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, including poor balance, reduced leg muscle strength, and freezing of gait, in patients with Parkinson’s disease.

For the study, 231 patients with Parkinson’s disease received their usual care or took part in an exercise program three times per week for six months. Each session consisted of 40 to 60 minutes of balance and leg-strengthening exercises. This minimally supervised exercise program was prescribed and monitored by a physical therapist, and participants performed most of the exercise at home. On average, 13% of the exercise sessions were supervised by a physical therapist.

Six months of falls data were available for 225 study participants, and one or more months of falls data were available for the remaining six participants. During the intervention period, 467 falls (4.1 per person) were reported in the exercise group, and 810 falls (7.0 per person) were reported in the control group. This difference in fall rate was not statistically significant.

Prespecified subgroup analysis, however, did reveal a significant interaction effect for disease severity. The number of falls by participants who exercised was reduced among people with less severe Parkinson’s disease, but not in those with more severe disease, compared with the number of falls for the control group. For participants with less severe disease, a 69% reduction in falls was reported in people who exercised, compared with those who did not.

“These results suggest that minimally supervised exercise programs aimed at reducing falls in people with Parkinson’s disease should be started early in the disease process,” Dr. Canning said. Because the progression of disease affects both motor and nonmotor systems, patients with more severe disease may derive more benefit from a multifactorial, closely supervised intervention, the researchers suggested. Overall, patients who took part in the exercise program performed better on tests of ability to move around and balance, had a lower fear of falls, and reported better overall mood and quality of life.

Exercise may help patients with Parkinson’s disease improve their balance, ability to move around, and quality of life, even if it does not reduce their risk of falling, according to a new study published online ahead of print December 31, 2014, in Neurology.

Falling is common among people with Parkinson’s disease. Approximately 60% of patients fall each year, and two-thirds of these individuals fall repeatedly. “The resulting injuries, pain, limitations of activity, and fear of falling again can really affect people’s health and well-being,” said study author Colleen G. Canning, PhD, Associate Professor of Physiotherapy at the University of Sydney.

Evidence from systematic reviews shows that exercise programs are effective in preventing falls in the general older population, so Dr. Canning and colleagues sought to determine whether falls can be prevented with minimally supervised exercise targeting potentially remediable fall risk factors, including poor balance, reduced leg muscle strength, and freezing of gait, in patients with Parkinson’s disease.

For the study, 231 patients with Parkinson’s disease received their usual care or took part in an exercise program three times per week for six months. Each session consisted of 40 to 60 minutes of balance and leg-strengthening exercises. This minimally supervised exercise program was prescribed and monitored by a physical therapist, and participants performed most of the exercise at home. On average, 13% of the exercise sessions were supervised by a physical therapist.

Six months of falls data were available for 225 study participants, and one or more months of falls data were available for the remaining six participants. During the intervention period, 467 falls (4.1 per person) were reported in the exercise group, and 810 falls (7.0 per person) were reported in the control group. This difference in fall rate was not statistically significant.

Prespecified subgroup analysis, however, did reveal a significant interaction effect for disease severity. The number of falls by participants who exercised was reduced among people with less severe Parkinson’s disease, but not in those with more severe disease, compared with the number of falls for the control group. For participants with less severe disease, a 69% reduction in falls was reported in people who exercised, compared with those who did not.

“These results suggest that minimally supervised exercise programs aimed at reducing falls in people with Parkinson’s disease should be started early in the disease process,” Dr. Canning said. Because the progression of disease affects both motor and nonmotor systems, patients with more severe disease may derive more benefit from a multifactorial, closely supervised intervention, the researchers suggested. Overall, patients who took part in the exercise program performed better on tests of ability to move around and balance, had a lower fear of falls, and reported better overall mood and quality of life.

The American Headache Society (AHS), working in cooperation with the American Academy of Neurology (AAN), has provided an updated assessment of the evidence for individual pharmacologic therapies for acute migraine treatment. The findings were published in the January issue of Headache. The study report was written by three headache specialists who are members of the Guidelines Section of the AHS: Michael J. Marmura, MD, Assistant Professor of Neurology, and Stephen D. Silberstein, MD, FACP, Director of the Headache Center, both at Thomas Jefferson University in Philadelphia, and Todd J. Schwedt, MD, MSCI, Associate Professor of Neurology at Mayo Clinic Arizona in Scottsdale.

It has been 15 years since the AAN and the US Headache Consortium published a complete set of evidence-based guidelines for the acute treatment of migraine. Since that publication, the AAN has updated its guideline-development process and criteria for evidence, basing recommendations largely on the quality of evidence in published literature. Although the AAN and the AHS updated the guidelines for the prevention of migraine in adults in 2012 using the newer criteria, a comparable effort to reassess pharmacotherapies for the acute treatment of migraine in adults was not undertaken until more recently.

Guideline Based on New Evidence and Criteria
In a guest editorial accompanying the study report in Headache, Drs. Silberstein and Marmura explain that the newer set of criteria used in the 2000 guidelines created a problem because many of the older drugs assessed at that time were rated by older criteria. “We have attempted to update these drugs when possible,” said the two authors. “The AHS Guidelines Committee is developing and will publish a companion piece to allow translation of the evidence-based guidelines to daily practice.”

By providing an updated assessment of the most effective treatments to use when a migraine attack occurs, the 2015 recommendations will form the basis of a new set of AHS treatment guidelines and, in the meantime, will help inform treatment choices by clinicians and facilitate doctor–patient discussion, according to the American Migraine Foundation, a nonprofit organization supported by the AHS.

“We hope that this assessment of the efficacy of currently available migraine therapies helps patients and their physicians utilize treatments that are the most appropriate for them,” stated Dr. Silberstein. “Several large, randomized acute pharmacologic migraine treatment trials have been conducted since the release of the 2000 AAN–AHS guidelines, so it was important that we update our guidelines to reflect the latest evidence.”

Triptans and Ergotamine Derivatives Were Considered Effective
For this latest assessment, the researchers conducted a systematic review of clinical trials published from 1998 to 2013 that compared the efficacy of acute migraine treatments versus that of placebo. A level of evidence was assigned to each drug based on the quality of its supporting studies. For an agent to be established as effective or ineffective (Level A), it had to be supported by at least two Class I studies. A rating of probably effective (or ineffective) (Level B) required one Class I study or two Class II studies, and a rating of possibly effective (or ineffective) (Level C) required one Class II study or two Class III studies. When evidence was either conflicting or inadequate to support the drug’s use, it was designated Level U.

The evaluation of the quality of each study was based on the AAN therapeutic classification of evidence scheme, ranging from Class I—well-designed double-blind, randomized, placebo-controlled trials—to Class IV, typically retrospective studies or case reports with unclear outcomes data.

Specific medications found to be effective for the acute therapy of migraine include agents in drug classes such as triptans (eg, almotriptan, eletriptan, frovatriptan, and various forms of sumatriptan and zolmitriptan), ergotamine derivatives (eg, the nasal spray and inhaler forms of dihydroergotamine [DHE]), and nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac and ibuprofen), as well as the combination medications sumatriptan–naproxen and acetaminophen–aspirin–caffeine. Other forms of DHE, NSAIDs such as ketoprofen, and antiemetics such as droperidol were found to be probably effective. Butalbital, phenazone, and dexamethasone were considered possibly effective.

The study authors noted that, in addition to a drug’s efficacy, clinicians should take into account potential side effects and adverse events, drug–drug interactions, and patient-specific contraindications to the use of a particular agent when prescribing medication for acute migraine therapy. For example, although opioids such as butorphanol, codeine–acetaminophen, and tramadol–acetaminophen are probably effective, they are not recommended for regular use because of concerns about tolerance and dependence.

From Expert Opinion to Evidence-Based Treatment
“This report focusing on acute migraine treatment reflects the changing nature of guidelines toward evidence-based treatment rather than expert opinion,” said Dr. Marmura. “Large, double-blind, placebo-controlled trials are the basis of determining the effectiveness of acute migraine treatment. Some clinical trials for headache performed prior to publication of the previous guidelines do not meet the more rigorous standards for clinical trials today.”

The authors of the 2015 study, which was funded by the AHS, emphasize that this reassessment focuses on the treatment of acute attacks, not long-term outcomes, while stressing the priority of individualizing treatment.

“Clinicians still need to individualize treatment and consider the clinical context of the migraine attack,” observed Dr. Marmura. “An outpatient with well-controlled episodic migraine may respond differently than someone with chronic migraine or a patient in the emergency room. This assessment does not provide guidance for long-term migraine management, including issues such as adverse events and medication-overuse headache.”

—Fred Balzac

The American Headache Society (AHS), working in cooperation with the American Academy of Neurology (AAN), has provided an updated assessment of the evidence for individual pharmacologic therapies for acute migraine treatment. The findings were published in the January issue of Headache. The study report was written by three headache specialists who are members of the Guidelines Section of the AHS: Michael J. Marmura, MD, Assistant Professor of Neurology, and Stephen D. Silberstein, MD, FACP, Director of the Headache Center, both at Thomas Jefferson University in Philadelphia, and Todd J. Schwedt, MD, MSCI, Associate Professor of Neurology at Mayo Clinic Arizona in Scottsdale.

It has been 15 years since the AAN and the US Headache Consortium published a complete set of evidence-based guidelines for the acute treatment of migraine. Since that publication, the AAN has updated its guideline-development process and criteria for evidence, basing recommendations largely on the quality of evidence in published literature. Although the AAN and the AHS updated the guidelines for the prevention of migraine in adults in 2012 using the newer criteria, a comparable effort to reassess pharmacotherapies for the acute treatment of migraine in adults was not undertaken until more recently.

Guideline Based on New Evidence and Criteria
In a guest editorial accompanying the study report in Headache, Drs. Silberstein and Marmura explain that the newer set of criteria used in the 2000 guidelines created a problem because many of the older drugs assessed at that time were rated by older criteria. “We have attempted to update these drugs when possible,” said the two authors. “The AHS Guidelines Committee is developing and will publish a companion piece to allow translation of the evidence-based guidelines to daily practice.”

By providing an updated assessment of the most effective treatments to use when a migraine attack occurs, the 2015 recommendations will form the basis of a new set of AHS treatment guidelines and, in the meantime, will help inform treatment choices by clinicians and facilitate doctor–patient discussion, according to the American Migraine Foundation, a nonprofit organization supported by the AHS.

“We hope that this assessment of the efficacy of currently available migraine therapies helps patients and their physicians utilize treatments that are the most appropriate for them,” stated Dr. Silberstein. “Several large, randomized acute pharmacologic migraine treatment trials have been conducted since the release of the 2000 AAN–AHS guidelines, so it was important that we update our guidelines to reflect the latest evidence.”

Triptans and Ergotamine Derivatives Were Considered Effective
For this latest assessment, the researchers conducted a systematic review of clinical trials published from 1998 to 2013 that compared the efficacy of acute migraine treatments versus that of placebo. A level of evidence was assigned to each drug based on the quality of its supporting studies. For an agent to be established as effective or ineffective (Level A), it had to be supported by at least two Class I studies. A rating of probably effective (or ineffective) (Level B) required one Class I study or two Class II studies, and a rating of possibly effective (or ineffective) (Level C) required one Class II study or two Class III studies. When evidence was either conflicting or inadequate to support the drug’s use, it was designated Level U.

The evaluation of the quality of each study was based on the AAN therapeutic classification of evidence scheme, ranging from Class I—well-designed double-blind, randomized, placebo-controlled trials—to Class IV, typically retrospective studies or case reports with unclear outcomes data.

Specific medications found to be effective for the acute therapy of migraine include agents in drug classes such as triptans (eg, almotriptan, eletriptan, frovatriptan, and various forms of sumatriptan and zolmitriptan), ergotamine derivatives (eg, the nasal spray and inhaler forms of dihydroergotamine [DHE]), and nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac and ibuprofen), as well as the combination medications sumatriptan–naproxen and acetaminophen–aspirin–caffeine. Other forms of DHE, NSAIDs such as ketoprofen, and antiemetics such as droperidol were found to be probably effective. Butalbital, phenazone, and dexamethasone were considered possibly effective.

The study authors noted that, in addition to a drug’s efficacy, clinicians should take into account potential side effects and adverse events, drug–drug interactions, and patient-specific contraindications to the use of a particular agent when prescribing medication for acute migraine therapy. For example, although opioids such as butorphanol, codeine–acetaminophen, and tramadol–acetaminophen are probably effective, they are not recommended for regular use because of concerns about tolerance and dependence.

From Expert Opinion to Evidence-Based Treatment
“This report focusing on acute migraine treatment reflects the changing nature of guidelines toward evidence-based treatment rather than expert opinion,” said Dr. Marmura. “Large, double-blind, placebo-controlled trials are the basis of determining the effectiveness of acute migraine treatment. Some clinical trials for headache performed prior to publication of the previous guidelines do not meet the more rigorous standards for clinical trials today.”

The authors of the 2015 study, which was funded by the AHS, emphasize that this reassessment focuses on the treatment of acute attacks, not long-term outcomes, while stressing the priority of individualizing treatment.

“Clinicians still need to individualize treatment and consider the clinical context of the migraine attack,” observed Dr. Marmura. “An outpatient with well-controlled episodic migraine may respond differently than someone with chronic migraine or a patient in the emergency room. This assessment does not provide guidance for long-term migraine management, including issues such as adverse events and medication-overuse headache.”

—Fred Balzac

The American Headache Society (AHS), working in cooperation with the American Academy of Neurology (AAN), has provided an updated assessment of the evidence for individual pharmacologic therapies for acute migraine treatment. The findings were published in the January issue of Headache. The study report was written by three headache specialists who are members of the Guidelines Section of the AHS: Michael J. Marmura, MD, Assistant Professor of Neurology, and Stephen D. Silberstein, MD, FACP, Director of the Headache Center, both at Thomas Jefferson University in Philadelphia, and Todd J. Schwedt, MD, MSCI, Associate Professor of Neurology at Mayo Clinic Arizona in Scottsdale.

It has been 15 years since the AAN and the US Headache Consortium published a complete set of evidence-based guidelines for the acute treatment of migraine. Since that publication, the AAN has updated its guideline-development process and criteria for evidence, basing recommendations largely on the quality of evidence in published literature. Although the AAN and the AHS updated the guidelines for the prevention of migraine in adults in 2012 using the newer criteria, a comparable effort to reassess pharmacotherapies for the acute treatment of migraine in adults was not undertaken until more recently.

Guideline Based on New Evidence and Criteria
In a guest editorial accompanying the study report in Headache, Drs. Silberstein and Marmura explain that the newer set of criteria used in the 2000 guidelines created a problem because many of the older drugs assessed at that time were rated by older criteria. “We have attempted to update these drugs when possible,” said the two authors. “The AHS Guidelines Committee is developing and will publish a companion piece to allow translation of the evidence-based guidelines to daily practice.”

By providing an updated assessment of the most effective treatments to use when a migraine attack occurs, the 2015 recommendations will form the basis of a new set of AHS treatment guidelines and, in the meantime, will help inform treatment choices by clinicians and facilitate doctor–patient discussion, according to the American Migraine Foundation, a nonprofit organization supported by the AHS.

“We hope that this assessment of the efficacy of currently available migraine therapies helps patients and their physicians utilize treatments that are the most appropriate for them,” stated Dr. Silberstein. “Several large, randomized acute pharmacologic migraine treatment trials have been conducted since the release of the 2000 AAN–AHS guidelines, so it was important that we update our guidelines to reflect the latest evidence.”

Triptans and Ergotamine Derivatives Were Considered Effective
For this latest assessment, the researchers conducted a systematic review of clinical trials published from 1998 to 2013 that compared the efficacy of acute migraine treatments versus that of placebo. A level of evidence was assigned to each drug based on the quality of its supporting studies. For an agent to be established as effective or ineffective (Level A), it had to be supported by at least two Class I studies. A rating of probably effective (or ineffective) (Level B) required one Class I study or two Class II studies, and a rating of possibly effective (or ineffective) (Level C) required one Class II study or two Class III studies. When evidence was either conflicting or inadequate to support the drug’s use, it was designated Level U.

The evaluation of the quality of each study was based on the AAN therapeutic classification of evidence scheme, ranging from Class I—well-designed double-blind, randomized, placebo-controlled trials—to Class IV, typically retrospective studies or case reports with unclear outcomes data.

Specific medications found to be effective for the acute therapy of migraine include agents in drug classes such as triptans (eg, almotriptan, eletriptan, frovatriptan, and various forms of sumatriptan and zolmitriptan), ergotamine derivatives (eg, the nasal spray and inhaler forms of dihydroergotamine [DHE]), and nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, diclofenac and ibuprofen), as well as the combination medications sumatriptan–naproxen and acetaminophen–aspirin–caffeine. Other forms of DHE, NSAIDs such as ketoprofen, and antiemetics such as droperidol were found to be probably effective. Butalbital, phenazone, and dexamethasone were considered possibly effective.

The study authors noted that, in addition to a drug’s efficacy, clinicians should take into account potential side effects and adverse events, drug–drug interactions, and patient-specific contraindications to the use of a particular agent when prescribing medication for acute migraine therapy. For example, although opioids such as butorphanol, codeine–acetaminophen, and tramadol–acetaminophen are probably effective, they are not recommended for regular use because of concerns about tolerance and dependence.

From Expert Opinion to Evidence-Based Treatment
“This report focusing on acute migraine treatment reflects the changing nature of guidelines toward evidence-based treatment rather than expert opinion,” said Dr. Marmura. “Large, double-blind, placebo-controlled trials are the basis of determining the effectiveness of acute migraine treatment. Some clinical trials for headache performed prior to publication of the previous guidelines do not meet the more rigorous standards for clinical trials today.”

The authors of the 2015 study, which was funded by the AHS, emphasize that this reassessment focuses on the treatment of acute attacks, not long-term outcomes, while stressing the priority of individualizing treatment.

“Clinicians still need to individualize treatment and consider the clinical context of the migraine attack,” observed Dr. Marmura. “An outpatient with well-controlled episodic migraine may respond differently than someone with chronic migraine or a patient in the emergency room. This assessment does not provide guidance for long-term migraine management, including issues such as adverse events and medication-overuse headache.”

—Fred Balzac

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb

Several proposed guidelines that limit neuroimaging for uncomplicated headaches in an effort to curb medical spending may delay diagnoses and worsen outcomes for patients with brain tumors, according to research published in the January issue of Neurosurgery. The various guidelines, which were introduced independently by the American Headache Society, the American College of Radiology, and Consumer Reports, “may reduce the perceived global economic burden at the expense of medical errors,” said the authors.

The investigators’ research examines the medical consequences of attempts to reduce waste in the medical field by limiting tests and procedures that patients request and physicians order. In particular, the authors cite the Choosing Wisely initiative and research by Frishberg et al.

“Although the intentions are laudable, these guidelines are inconsistent with the neurosurgeon’s experience with patients with brain tumor,” said Ammar H. Hawasli, MD, PhD, neurosurgery resident at Washington University School of Medicine in St. Louis, and colleagues. “We support careful and sensible use of neuroimaging in which physicians exercise excellent clinical judgment to reduce waste in the medical system.”

Dr. Hawasli and colleagues retrospectively reviewed medical records for patients who were diagnosed with a brain neoplasm from an open brain biopsy. The investigators reviewed preoperative histories and physical examinations for presenting symptoms. Patients underwent superficial open brain biopsies performed through a small craniotomy to obtain diagnostic pathology. Dr. Hawasli and colleagues reviewed the pathology reports and included only patients with neoplasms in the study.

Of patients with a brain tumor, 7.4% presented with seizures, 13.7% presented with cognitive and speech dysfunction, 6% presented with isolated focal symptoms (ie, motor, sensory, or visual), 10% presented with nonfocal symptoms, 48% presented with a combination of symptoms, 3% presented with asymptomatic lesions that were found incidentally on unrelated radiographic examinations, and 11.6% presented with isolated headaches. “Hence, 24.2% of patients with brain tumors diagnosed by brain biopsy presented with isolated headaches, no symptoms, or nonspecific symptoms,” said the authors.

Four of 11 patients with isolated headache presented with new-onset symptomology and thus qualified for imaging according to the proposed guidelines. The other seven patients had nonacute isolated headaches. The duration of these patients’ headaches prompted the referring physicians to request neuroimaging that revealed brain tumors. Three of the seven patients presented with migrainous, unilateral headaches without any recent change. The other four patients presented with stable, nonacute headaches without a clear migraine component.

“If the recommendations by Loder et al and Frishberg et al had been followed, diagnosis would have been delayed or missed for these three of 11 patients with isolated headaches (3.2% of all patients with brain tumor),” said Dr. Hawasli. “If the American College of Radiology/Consumer Reports recommendations had been followed, a diagnostic delay or error would have occurred for seven of 11 patients with isolated headaches (7.4% of all patients). Hence, under the proposed guidelines, neuroimaging may have been delayed or missed in 3% to 7% of patients with brain tumors.”

The study results suggest that neurosurgeons frequently treat patients with brain tumor who present with headaches alone, nonspecific symptoms, or incidentally. “The premise that brain tumors always present with more than headaches is incorrect,” said Dr. Hawasli. “Assuming this false premise may lead to medical errors.”

Although neuroimaging may increase healthcare costs, it is the primary means of diagnosis for patients with brain tumors, said the authors. The ordering of tests also is associated with a reduction in medical errors and malpractice liability costs, they added. Failure to diagnose a brain tumor because of a lack of imaging may increase costs because of delays in treatment. “Ordering imaging would allow prompt diagnosis and care, which are associated with improved outcomes,” said Dr. Hawasli.

“The ostensible friction between patient-tailored medicine and population medicine initiatives underscores the need for further research to develop guidelines on neuroimaging for headaches,” he added. “The current guidelines constitute Level 4 clinical decision rule criteria, which suggest that they require further evaluation before they can be applied clinically.”

—Erik Greb

Initial treatment with parenteral opiates is associated with an increased length of hospital stay among patients presenting to an emergency department with acute primary headache, according to research published online ahead of print November 3, 2014, in Cephalalgia. This treatment also may be associated with an increased rate of return visits to the emergency department within seven days.

Lucas H. McCarthy, MD, a neurologist at Puget Sound VA Healthcare System in Seattle, and Robert Cowan, MD, Professor of Neurology and Neurological Sciences at Stanford University in California, conducted a retrospective chart review to compare outcomes for patients with acute primary headache initially treated with parenteral opiates or nonopiate recommended headache medications in a large academic medical emergency department (Stanford Emergency Department). Eligible patients were age 18 or older, and the researchers excluded people with any secondary cause for headache.

Recommended Medications
Medications included as recommended in a systematic review of acute migraine treatments and in the Canadian Headache Society guideline for acute migraine treatment in the emergency department were classified as first-line recommended treatments. The list of these drugs included prochlorperazine, metachlopramide, chlorpromazine, ketorolac, aspirin, acetaminophen, triptans, and dihydroergotamine. The researchers analyzed potential confounders such as headache severity, number of medications given, the performance of neuroimaging, duration of hospital stay, and return visits to the emergency department.

Neuroimaging Linked to Early Return Visits
A total of 574 people were included in the final analysis. In all, 303 (52.6%) participants received nonopiate first-line recommended parenteral headache agents as initial agents, and 131 (22.8%) individuals received opiates as initial agents. The remaining 140 (24.4%) patients initially received an alternative parenteral medication.

Median length of hospital stay for all patients was 4.5 hours. Those patients given opiates initially had a univariate 3.9 times higher odds of having a long stay, compared with patients given first-line recommended medications. This association remained significant after the investigators adjusted the results for possible confounders.

Furthermore, 69 participants had at least one readmission for headache during the study period, and 20 individuals returned to the emergency department within seven days. Patients who had neuroimaging had significantly higher rates of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended agents. When the investigators added neuroimaging to the multivariable analysis, the association between initial opiate use and early return visits was no longer significant.

The association between longer length of stay and initial opiate use likely reflects a class effect, because “opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications,” said Dr. McCarthy. The authors acknowledged that the retrospective nature of the study limited their ability to establish cause and effect, however. “Encouraging the initial use of first-line recommended headache medications rather than opiates in all acute primary headaches (regardless of migraine diagnosis) … could improve patient outcomes,” they concluded.

Acute Diagnosis May Not Be Necessary
“Regardless of whether the acute headache takes the form of migraine or tension-type headache, it is likely to respond to most nonopioid parenteral treatments, including subcutaneous sumatriptan, metoclopramide, and ketorolac,” said Benjamin W. Friedman, MD, Associate Professor in the Department of Emergency Medicine at Albert Einstein College of Medicine in the Bronx, New York, and David R. Vinson, MD, of Kaiser Permanente Sacramento Medical Center in California, in an accompanying editorial. “We do our best to provide our patients with a specific diagnosis, but because the vast majority of primary headaches in the emergency department take the form of migraine or tension-type headache, diagnosis is not necessary acutely.

“The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department,” Dr. Vinson concluded.

—Erik Greb

Initial treatment with parenteral opiates is associated with an increased length of hospital stay among patients presenting to an emergency department with acute primary headache, according to research published online ahead of print November 3, 2014, in Cephalalgia. This treatment also may be associated with an increased rate of return visits to the emergency department within seven days.

Lucas H. McCarthy, MD, a neurologist at Puget Sound VA Healthcare System in Seattle, and Robert Cowan, MD, Professor of Neurology and Neurological Sciences at Stanford University in California, conducted a retrospective chart review to compare outcomes for patients with acute primary headache initially treated with parenteral opiates or nonopiate recommended headache medications in a large academic medical emergency department (Stanford Emergency Department). Eligible patients were age 18 or older, and the researchers excluded people with any secondary cause for headache.

Recommended Medications
Medications included as recommended in a systematic review of acute migraine treatments and in the Canadian Headache Society guideline for acute migraine treatment in the emergency department were classified as first-line recommended treatments. The list of these drugs included prochlorperazine, metachlopramide, chlorpromazine, ketorolac, aspirin, acetaminophen, triptans, and dihydroergotamine. The researchers analyzed potential confounders such as headache severity, number of medications given, the performance of neuroimaging, duration of hospital stay, and return visits to the emergency department.

Neuroimaging Linked to Early Return Visits
A total of 574 people were included in the final analysis. In all, 303 (52.6%) participants received nonopiate first-line recommended parenteral headache agents as initial agents, and 131 (22.8%) individuals received opiates as initial agents. The remaining 140 (24.4%) patients initially received an alternative parenteral medication.

Median length of hospital stay for all patients was 4.5 hours. Those patients given opiates initially had a univariate 3.9 times higher odds of having a long stay, compared with patients given first-line recommended medications. This association remained significant after the investigators adjusted the results for possible confounders.

Furthermore, 69 participants had at least one readmission for headache during the study period, and 20 individuals returned to the emergency department within seven days. Patients who had neuroimaging had significantly higher rates of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended agents. When the investigators added neuroimaging to the multivariable analysis, the association between initial opiate use and early return visits was no longer significant.

The association between longer length of stay and initial opiate use likely reflects a class effect, because “opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications,” said Dr. McCarthy. The authors acknowledged that the retrospective nature of the study limited their ability to establish cause and effect, however. “Encouraging the initial use of first-line recommended headache medications rather than opiates in all acute primary headaches (regardless of migraine diagnosis) … could improve patient outcomes,” they concluded.

Acute Diagnosis May Not Be Necessary
“Regardless of whether the acute headache takes the form of migraine or tension-type headache, it is likely to respond to most nonopioid parenteral treatments, including subcutaneous sumatriptan, metoclopramide, and ketorolac,” said Benjamin W. Friedman, MD, Associate Professor in the Department of Emergency Medicine at Albert Einstein College of Medicine in the Bronx, New York, and David R. Vinson, MD, of Kaiser Permanente Sacramento Medical Center in California, in an accompanying editorial. “We do our best to provide our patients with a specific diagnosis, but because the vast majority of primary headaches in the emergency department take the form of migraine or tension-type headache, diagnosis is not necessary acutely.

“The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department,” Dr. Vinson concluded.

—Erik Greb

Initial treatment with parenteral opiates is associated with an increased length of hospital stay among patients presenting to an emergency department with acute primary headache, according to research published online ahead of print November 3, 2014, in Cephalalgia. This treatment also may be associated with an increased rate of return visits to the emergency department within seven days.

Lucas H. McCarthy, MD, a neurologist at Puget Sound VA Healthcare System in Seattle, and Robert Cowan, MD, Professor of Neurology and Neurological Sciences at Stanford University in California, conducted a retrospective chart review to compare outcomes for patients with acute primary headache initially treated with parenteral opiates or nonopiate recommended headache medications in a large academic medical emergency department (Stanford Emergency Department). Eligible patients were age 18 or older, and the researchers excluded people with any secondary cause for headache.

Recommended Medications
Medications included as recommended in a systematic review of acute migraine treatments and in the Canadian Headache Society guideline for acute migraine treatment in the emergency department were classified as first-line recommended treatments. The list of these drugs included prochlorperazine, metachlopramide, chlorpromazine, ketorolac, aspirin, acetaminophen, triptans, and dihydroergotamine. The researchers analyzed potential confounders such as headache severity, number of medications given, the performance of neuroimaging, duration of hospital stay, and return visits to the emergency department.

Neuroimaging Linked to Early Return Visits
A total of 574 people were included in the final analysis. In all, 303 (52.6%) participants received nonopiate first-line recommended parenteral headache agents as initial agents, and 131 (22.8%) individuals received opiates as initial agents. The remaining 140 (24.4%) patients initially received an alternative parenteral medication.

Median length of hospital stay for all patients was 4.5 hours. Those patients given opiates initially had a univariate 3.9 times higher odds of having a long stay, compared with patients given first-line recommended medications. This association remained significant after the investigators adjusted the results for possible confounders.

Furthermore, 69 participants had at least one readmission for headache during the study period, and 20 individuals returned to the emergency department within seven days. Patients who had neuroimaging had significantly higher rates of early return visits, compared with those who did not have neuroimaging. Approximately 8% of people given opiates had early return visits, compared with 3% of patients given first-line recommended agents. When the investigators added neuroimaging to the multivariable analysis, the association between initial opiate use and early return visits was no longer significant.

The association between longer length of stay and initial opiate use likely reflects a class effect, because “opiates have shown less headache pain reduction, higher rates of headache recurrence, and increased sedation, compared with first-line recommended specific headache medications,” said Dr. McCarthy. The authors acknowledged that the retrospective nature of the study limited their ability to establish cause and effect, however. “Encouraging the initial use of first-line recommended headache medications rather than opiates in all acute primary headaches (regardless of migraine diagnosis) … could improve patient outcomes,” they concluded.

Acute Diagnosis May Not Be Necessary
“Regardless of whether the acute headache takes the form of migraine or tension-type headache, it is likely to respond to most nonopioid parenteral treatments, including subcutaneous sumatriptan, metoclopramide, and ketorolac,” said Benjamin W. Friedman, MD, Associate Professor in the Department of Emergency Medicine at Albert Einstein College of Medicine in the Bronx, New York, and David R. Vinson, MD, of Kaiser Permanente Sacramento Medical Center in California, in an accompanying editorial. “We do our best to provide our patients with a specific diagnosis, but because the vast majority of primary headaches in the emergency department take the form of migraine or tension-type headache, diagnosis is not necessary acutely.

“The most important intervention emergency physicians can deliver for their headache patients is to connect them with outpatient physicians savvy about headache management, who will then provide these headache patients with appropriate acute therapeutics, initiate preventive therapy, and counsel their patients against receiving opioids in the emergency department,” Dr. Vinson concluded.

—Erik Greb