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Head Ache

Medical Societies Release Top Five Lists of Don’ts

By Margaret Jaworski

As part of Choosing Wisely, a national campaign by the American Board of Internal Medicine (ABIM) Foundation aimed at sparking conversations between doctors and patients about what care is appropriate for their condition, avoiding unnecessary testing and treatment as well as reducing medical costs, over two dozen medical societies have, or are compiling, a list of  “Five Things” identifying procedures and treatments that doctors and their patients should question.

The American Academy of Neurology (AAN) released its list on February 21 in the online issue of Neurology. Two of the five recommendations dealt with pain issues.

1) Don’t perform electroencephalography (EEG) for headaches. Recurrent headache is the most common pain problem, affecting up to 20 percent of people. The recommendation states that EEG has no advantage over clinical evaluation in diagnosing headache, does not improve outcomes, and increases costs.

2) Don’t use opioid or butalbital treatment for migraine except as a last resort. Opioid and butalbital treatment for migraine should be avoided because more effective, migraine-specific treatments are available. Frequent use of opioid and butalbital treatment can worsen headaches. Opioids should be used only for those with medical conditions preventing the use of migraine-specific treatments or for those who fail these treatments.

The American College of Rheumatology’s list contained the following caveat regarding pain medication:

1) Don’t prescribe biologics for rheumatoid arthritis before a trial of methotrexate (or other conventional non-biologic DMARDs). High quality evidence suggests that methotrexate and other conventional non-biologic disease modifying antirheumatic drugs (DMARD) are effective in many patients with rheumatoid arthritis (RA). Initial therapy for RA should be conventional non-biologic DMARDs unless these are contraindicated. If a patient has had an inadequate response to methotrexate with or without other non-biologic DMARDs during an initial 3-month trial, then biologic therapy can be considered. Exceptions include patients with high disease activity and poor prognostic features (functional limitations, disease outside the joints, seropositivity or bony damage), where biologic therapy may be appropriate first-line treatment. For useful tips on how to live easier with RA, please read the following Pain Resource article.

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