Four Things Physicians and Patients Should Question

Released October 30, 2015


Don’t order neuroimaging or sinus imaging in patients who have a normal clinical examination, who meet diagnostic criteria for migraine, and have no “red flags” for a secondary headache disorder.

Red flags for a secondary headache include thunderclap onset, fever and meningismus, papilloedema, unexplained focal neurological signs, unusual headache attack precipitants, and headache onset after age 50. The yield of neuroimaging in patients with typical recurrent migraine attacks is very low. Any imaging study, particularly MRI, can identify incidental findings of no clinical significance which may lead to patient anxiety and further unnecessary investigation. For patients with typical migraine and a normal clinical examination who desire reassurance, careful explanation of the diagnosis and patient education may be more advisable.


Don’t prescribe opioid analgesics or combination analgesics containing opioids or barbiturates as first line therapy for the treatment of migraine.

Non-steroidal anti-inflammatory drugs and triptans are recommended first line treatments for acute migraine therapy. Opioids may produce increased sensitivity to pain and increase the risk that intermittent headache attacks will become more frequent and escalate to a chronic daily headache syndrome (medication overuse headache), particularly when opioids are used on 10 days a month or more. Opioids may impair alertness and produce dependence or addiction syndromes.


Don’t prescribe acute medications or recommend an over-the-counter analgesic for patients with frequent migraine attacks without monitoring frequency of acute medication use with a headache diary.

All acute medications used for migraine attacks, when used too frequently, increase the risk of medication overuse headache with progression to a chronic daily headache syndrome. Use of opioids, triptans, ergotamines, or combination analgesics of any kind on 10 days a month or more, and use of NSAIDs or acetaminophen on 15 days a month or more places patients at risk for medication overuse headache. Patients with migraine should be educated with regard to these risks.


Don’t forget to consider the behavioural components of migraine treatment, including lifestyle issues like regular and adequate meals and sleep, and management of specific triggers including stress.

Lifestyle issues and specific trigger management can contribute considerably to successful migraine control. Patient education regarding these factors may reduce the need for expensive medications and reduce indirect costs related to disability. Training in relaxation and other stress management techniques should be considered. Training in other skills like pacing activities to help patients manage their schedules and stress levels well, and how to take acute medications appropriately are also important.

How the list was created

The Canadian Headache Society (CHS) executive agreed to participate in the Choosing Wisely Canada campaign. A list of potential statements for Choosing Wisely Canada was created through email discussion among the executive, and input was then sought from other CHS directors. The refined statement list was then brought to the June 2015 Annual General Meeting of the Society where they were discussed and further input was obtained. Following this, draft versions were circulated and refined among the CHS executive and directors, and a final version was produced with the assistance of individuals from the Choosing Wisely Canada campaign.



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