Appropriateness Criteria for Neuroimaging of Adult Headache Patients in the Emergency Department: How Are We Doing?

The American College of Radiology (ACR) developed Appropriateness Criteria (ACR-AC) for diagnostic imaging to reduce overuse and promote high-yield, cost-effective, evidence-based decision-making. For adult headaches, there are 16 variants with specific imaging recommendations. Headache accounts for 4.5% of emergency department (ED) visits, and 61% are chronic. Imaging for headaches has increased in the past 2 decades, with intracranial pathology diagnoses going down. Evidence suggests that there is poor knowledge of the ACR-AC among advanced practice nurses (APNs) and nonradiologist physicians. The ACR-AC recommendations were examined using the Health Care Cost and Utilization Project State Emergency Department Data (HCUP SEDD) from Maryland in 2013. Imaging proportions were examined, as well as differences between residency program hospitals and hospitals that have APNs in the ED. Of the 11,109 chronic headache visits, a quarter underwent computed tomography ([CT]; 26.9%) and 3.6% underwent magnetic resonance imaging (MRI); the ACR-AC does not recommend use of either of these in patients with chronic headache. There were significant practice differences related to hospital teaching and whether APNs were employed in the ED or not. For patients with posttraumatic headache, there were no significant differences in practice. Computed tomography was used in 76.4% of posttraumatic headache visits. It is unknown whether the ACR-AC are being used in the ED, and there is variability in following the recommendations. Posttraumatic headache protocol is well established in the ED, but chronic headache continues to be a problem in imaging overuse despite recommendations. Radiological education, including the ACR-AC, as well as radiation dosing and exposure information should be part of APN, physician, and registered nurse education, as well as continuing education. Continuing education is critical for adherence to the ACR-AC, as the recommendations are complex and continuously evolving. In addition, to minimize overuse of CT in headaches, the ACR-AC should be integrated into clinical decision support to promote best imaging practices.