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Severe headaches are a misery, whether they cause a dull ache or a steady, stabbing, or blinding pain. Writer and migraine sufferer Stephen King described a character鈥檚 migraine attacks this way in the novel Firestarter: 鈥淭he headache would get worse until it was a smashing weight, sending red pain through his head and neck with every pulse beat. Bright lights would make his eyes water helplessly and send darts of agony into the flesh just behind his eyes. Small noises magnified, ordinary noises insupportable.鈥�

The pain of even a severe headache rarely comes from something catastrophic like a tumor or a bleeding in the brain. But fear of such cerebral catastrophes often drives people to get brain scans. According to a , about one in 10 people who seek outpatient care for severe headaches ultimately end up having a brain scan with computed tomography (CT) or magnetic resonance imaging (MRI). Most of them find nothing wrong.

People struck with agonizing headaches from migraines and other causes often turn to brain scanning when they don鈥檛 get what they really want from doctors. 鈥淎ctually, they want effective treatment, not scanning,鈥� says Dr. Egilius Spierings, a neurologist at Harvard-affiliated Brigham and Women鈥檚 Hospital.

Some primary care doctors don鈥檛 know enough about the most effective treatments for migraine and other headaches, says Dr. Spierings. That means some people who have migraines don鈥檛 get the medications they need, or aren鈥檛 given enough information about how best to use them.

鈥淭he focus should be on getting effective relief when you have a headache,鈥� says Dr. Spierings, medical editor of Headaches: Relieving and preventing migraine and other headaches, a Harvard Medical School Special Health Report. 鈥淚f people get the right treatment, meaning the one that works for them, doctors don鈥檛 feel the need to do any neuroimaging.鈥�

Scans for headaches

To get a handle on how many people with severe headaches get CTs and MRIs, Michigan researchers scrutinized data from the National Ambulatory Medical Care Survey on physician office visits. They tallied more than 50 million headache visits made from 2007 to 2010, about half of them for migraine. Brain scans were done about 12% of the time. The cost of these scans to the healthcare system was $3.9 billion ($1.5 billion for migraine-related scans).

Excessive brain scanning costs more than just dollars. Repeated CT scans expose you to enough x-rays to raise the risk of cancer down the road. Scans also tend to lead to more scanning if the test turns up something strange, even though many of these incidental findings turn out to be nothing especially dangerous. Out of all the brains scans done for headache, perhaps 1% to 3% will reveal something abnormal. And most of these 鈥渁bnormalities鈥� aren鈥檛 something to worry about, like a tumor or a bleeding artery in the brain.

Overuse of brain imaging for headaches is not exactly a news flash in the medical profession. In fact, the American Board of Internal Medicine鈥檚 campaign discourages neuroimaging for 鈥渦ncomplicated鈥� headaches. To do its part, the American College of Radiology included 鈥淒on鈥檛 do imaging for uncomplicated headache鈥� on its that doctors and their patients should think twice about.

Yet the use of headache-related brain scans is on the rise. In their JAMA Internal Medicine paper, the researchers reported that headache-related brains scans increased from 5% of headache visits in 1995 to 14.7% in 2010.

What drives the continued overuse of brain imaging, despite experts鈥� urgings? In part, it comes from a need to rule out rare but dangerous causes of headache when the usual tools fail to do that.

鈥淚f you go to the doctor with a bad headache a couple of times, and the doctor has given you a few drugs but the headache doesn鈥檛 get any better, you and the doctor will start worrying that this headache is from something else,鈥� Dr. Spierings says. 鈥淚f it鈥檚 not possible to rule out structural problem in the brain, then it鈥檚 an easy step to order an MRI.鈥� Insurers usually pay for these scans, too鈥攅ven though the vast majority of headaches aren鈥檛 caused by a tumor or other serious brain problem.

Migraine standard of care

Many people who consult their primary care doctors because of severe and recurrent migraine headaches don鈥檛 actually get what they need鈥攏o pain, says Dr. Spierings.

Drugs called triptans can stop the headache within two hours, provided the drug is taken when the headache is still mild. If it doesn鈥檛 stop within two hours, you may need to take more medication. Later on, other medications can be taken to help prevent future attacks.

It鈥檚 important to take migraine medicine as directed. 鈥淲ith migraine treatment you always need to treat right away, you have to make sure the dose is high enough, and you always have to repeat two hours later if the headache is not fully gone,鈥� says Dr. Spierings.

Of course, all of these drugs have potential side effects, and the pros and cons should be weighed carefully. But they work for many people if they are used properly, Dr. Spierings emphasizes.

When to see a doctor

Headaches come in three varieties: Tension, sinus, and migraine. More than 95% of headaches aren鈥檛 caused by an underlying disease or structural abnormality. Instead, they spring from common conditions such as stress, fatigue, lack of sleep, hunger, changes in estrogen level, weather changes, or caffeine withdrawal. Most people don鈥檛 need a doctor visit or a brain scan. Instead, they need over-the-counter pain relievers (such as aspirin, acetaminophen, ibuprofen, and naproxen) or prescription medications, rest, and relaxation.

If you find yourself taking painkillers for headaches more than a couple of times a week, see your doctor. Red flags that signal the need for medical evaluation include:

• Not having had headaches before
• Headaches that worsen over the course of a few weeks
• A headache that comes on fast (seconds)
• Headache associated with fever
• Severe headache in an older person
• Headache associated with symptoms or signs like swelling in the back of the eyes