Letter re: Neuroimaging overuse is more common in Medicare compared with the VA

In their article, Burke et al.¹ stated, “neuroimaging overuse appears to be high in both…populations.” This statement, as related to headache, is based on a retrospective analysis with the definition of overuse predicated on the United States Headache Consortium Guidelines, which recommended that neuroimaging is not warranted for patients with migraine and a normal neurologic examination.² These guidelines, in relation to migraine, stem from a meta-analysis of 11 outdated studies with serious methodologic flaws, underestimating the incidence of intracranial abnormalities in migraine patients with a normal examination.^3,4 Thus, the authors' conclusion that “inappropriate neuroimaging for headache…is relatively common” is simply untenable, and promoting “interventions to curb overutilization” represents a misguided approach that should be avoided until further research delineates relevant guidelines that properly “correlate intracranial abnormalities with individual patient data, headache patterns, underlying diseases, associated conditions, imaging protocols, and related factors.”⁴ Blind adherence to outdated data remains detrimental to patient care, increases physician liability, and ensures that misdiagnosis of headache will continue its reign as the most common diagnostic error in neurology, leading to increasingly expensive jury verdicts and settlements against unsuspecting neurologists following flawed guidelines.