Grand Rounds Blog

Grand Rounds is committed to partnering with employers to connect their employees with the highest quality physicians. In evolving our physician quality algorithm, our Data Science team is continually evaluating physicians’ clinical practice patterns, and the results paint a stark portrait of medicine today.

HEADACHE TREATMENT: Not all doctors are created equal.

The health and economic impacts of headaches are immense. Each year, more than thirty million American adults suffer from migraines or other severe forms of headache.1 Estimates suggest that annual indirect costs of headaches to employers reach $13 billion nationally due to absenteeism and reduced productivity while at work, not to mention billions more in direct medical costs.2

Chart each year 30 million American adults suffer from migraine or severe headache

There are huge variations in quality of care when it comes to the treatment of headaches, specifically with respect to inappropriate prescribing decisions. Many of the medications that offer short-term relief from the intensity of a headache can actually lead to increasing headache severity and frequency over time. This problem has become so widespread that “medication overuse headache” (MOH), itself, is now estimated to account for 20% of the total headache disease burden.3

Our analysis of physician prescribing patterns suggests that headache patients’ risk of receiving inappropriate prescriptions depends largely on the doctor they choose to see. The risk of medication overuse headache is particularly high with opioids and barbiturates. Well-informed physicians will only resort to using opioids or barbiturates for headaches as an option of absolute last resort (if at all), yet surveys show that many doctors remain shockingly unaware of the risks associated with these medications. For example, a National Headache Foundation survey found that only 54% of primary care physicians are aware that barbiturates cause medication overuse headache.4

To understand the magnitude of this issue, we analyzed the rate at which primary care physicians and neurologists prescribe the three medications believed to be most responsible for causing medication overuse headache: butalbital (a barbiturate), hydrocodone, and oxycodone (the two opioids most commonly prescribed for headaches). The results of our analysis were eye-opening: within each specialty, physicians whose overall quality rates in the bottom 10% are prescribing butalbital to headache patients four to five times more often than their top decile peers. Similarly, bottom decile physicians are prescribing opioids at nearly double and triple the rates of their highest rated peers.

Low-Quality Doctors Prescribe Significantly More Addictive Medications for Headaches

The ramifications of the prescribing habits of these bottom decile physicians cannot be understated. The opioid epidemic in the U.S. has reached staggering new heights, resulting in over one thousand overdose deaths per month from prescription opioids alone.5 Between 1999 and 2014, sales of prescription opioids in the U.S. have nearly quadrupled.6 Meanwhile, butalbital prescribing has become so problematic that many European countries have resorted to banning the medication entirely. In the U.S., though, it remains available and accounts for a remarkable 15% of total headache prescriptions each year.7 In response to a recent study on the frequency with which these medications are prescribed for headaches, the President of the American Headache Society remarked, “[This] both surprises and dismays me… We’ve known for years that the use of opioids and barbiturates are inappropriate.”8

The disparity in prescribing across physicians suggests a patient’s chances of developing medication overuse headache can be dramatically reduced by simply ensuring that they are treated by a doctor who understands the risks associated with opioids and barbiturates and knows to use them only as a line of last resort. For the patient, this can mean the difference between a quick, effective course of treatment and a life-altering addiction. For employers, billions of dollars in medical costs and lost productivity are at stake. Many healthcare challenges are exceptionally difficult to solve. When it comes to treating a headache, simply seeing the right doctor can make all the difference.

Using more than seven billion data points, Grand Rounds has assessed over 96% of practicing physicians in the United States to identify the highest quality doctors in each specialty. As an employer, partnering with Grand Rounds can help your employees find physicians with the skill and judgment needed to guide your employees on the best clinical path.

Read additional analyses in the Grand Rounds Data Insights series here.





  1. “The Prevalence and Burden of Migraine and Severe Headache in the United States: Updated Statistics From Government Health Surveillance Studies,” National Center for Biotechnology Information,, January 2015.
  2. “Epidemiology and Impact of Headache and Migraine,” American Headache Society,, July 2016.
  3. “Global, Regional, and National Incidence, Prevalence, and Years Lived With Disability for 310 Diseases and Injuries, 1990–2015: A Systematic Analysis for the Global Burden of Disease Study 2015,” The Lancet,, January 2017.
  4. “NHF Survey – Migraine-Specific Medications vs. Nonspecific Medications for Acute Treatment,” HealthCentral,, May 2007.
  5. “Prescription Opioid Overdose Data,” Centers for Disease Control and Prevention,, August 2017.
  6. “Prescribing Data,” Centers for Disease Control and Prevention,, accessed September 2017.
  7. “Sumatriptan-naproxen and Butalbital: A Double-blind, Placebo-controlled Crossover Study,” National Center for Biotechnology Information,, April 2012.
  8. “Too Many Patients With Migraine Receiving Opioids, Barbiturates,” Miriam E. Tucker, Medscape,, June 2015.
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