Neurologist and Attorney James C. Johnston, MD, JD, FAAN and his colleague neurologist Mehila Zebenigus, MD have discussed the proper use of neuroimaging in the diagnosis of headache disorders at the World Congresses for Medical Law in Los Angeles, Baku and Tel Aviv, and at the most recent American Academy of Neurology conference in Philadelphia.  

The failure to properly diagnose the patient with headache remains one of the most common diagnostic errors in neurology, and that has not improved over the past three decades despite significant advances in neuroimaging.  

There are various reasons for this recurrent error:  a significant number of patients with brain tumors have an unremarkable presentation; many patients with secondary headache present with the features of a migraine or tension headache; certain tumors mimic particular headache syndromes; and the inexperienced, poorly trained or hurried neurologist may overlook the subtle warning signs of a secondary headache.  

However, the failure is at least partially attributable to the United States Headache Consortium guidelines which state that neuroimaging is not warranted in patients with migraine and a normal examination.  These guidelines were based on a very small number of retrospective, flawed and outdated studies incorrectly reporting a 0.2% incidence of intracranial abnormalities in patients with headache and a normal exam.  The guideline authors considered this incidence too low to warrant an MRI for these patients.

But James C. Johnston, MD, JD summarized more recent data extrapolated from thousands of MRIs demonstrating the true incidence of intracranial abnormalities actually ranges from 3 - 5% depending on age and other factors.  These abnormalities included brain tumors, cysts, aneurysms, vascular changes and a number of other conditions, some benign but others requiring further investigation, monitoring or treatment.   

Unfortunately, many physicians continue to follow the outdated guidelines, perpetuating the misdiagnosis of headaches.  Some neurologists have even recommended further restricting MRIs in the name of cost containment, failing to recognize the enormous cost of headache misdiagnosis.

Drs. Johnston and Zebenigus recommend deleting the outdated guidelines until imaging protocols are prudently refined through well designed prospective studies focused on improving patient care.  In the intervening time, more aggressive imaging of the patient with headache is warranted.  They have published these recommendations in several peer reviewed journal articles in Neurologic Clinics; Headache; Neurology; and Medical Law; as well as several chapters in leading textbooks including Legal Medicine and Medical Ethics and Legal and Forensic Medicine.  

James C. Johnston, MD, JD is the founding partner of GlobalNeurology® and works closely with Professor Mehila Zebenigus, both serving as Directors of Global NeuroCare®, a nonprofit dedicated to advancing neurology services in developing regions.  They are currently performing a prospective study on imaging in the patient presenting with new onset headaches, and anticipate discussing the data at the 2020 World Congress of Medical Law.    

  

A board-certified neurologist with additional certification in rehabilitation, Dr. James C. Johnston has been in private practice for more than 30 years. James C. Johnston, MD, JD, focuses on advancing global health in an effort to improve neurological care for the most vulnerable populations in the most impoverished regions, especially in sub-Saharan Africa and particularly Ethiopia, one of the least developed nations on the planet.

Dr. James C. Johnston is an Honorary Professor of Neurology at Addis Ababa University, and established the 501(c)(3) non-profit organization Global NeuroCare to advance physician training, improve patient care and further medical research in Ethiopia and other developing regions. Global NeuroCare is accredited by the World Health Organization, and holds Special Consultative Status with the United Nations ECOSOC. 

On behalf of Global NeuroCare, James C. Johnston, MD, JD strongly recommends forming ethically congruent collaborative partnerships focused on establishing self-sufficient local training programs in order to advance the recruitment, development, training and retention of healthcare workers in developing regions and thus improve healthcare access while protecting vulnerable populations. And Dr. Johnston condemns the harmful practices engendered by academic institutions engaging in self-serving medical missions which fail to provide any substantive benefit to the host nations and, in fact, impedes development of local medical care in the very regions it is most needed. (E/2019/NGO/19 Statement at 2019 High Level Political Forum). 

This is the most effective means of improving neurological services - training local physicians, to treat local conditions, with the limited available resources in their community, followed by a focus on expanding resources. This is the approach adopted in Ethiopia through the neurology residency training program which has graduated over 50 neurologists in the past decade. These neurologists are treating many thousands of patients but more importantly, they are training the next generation of doctors how to manage common neurological conditions such as stroke, epilepsy, neuropathy, headache and similar disorders.

Dr. James C. Johnston and his Ethiopian colleague Professor Mehila Zebenigus have presented their recommendations and findings at the American Academy of Neurology meetings in Los Angeles and Philadelphia, and the World Congress for Medical Law conferences in Baku, Tel Aviv and Tokyo. In 2018, the World Association for Medical Law in conjunction with the Israeli Ministry of Health and Tel Aviv University honored Drs. Johnston and Zebenigus with the Inaugural Davies Award in Public Health for their work through Global NeuroCare. ​

​Dr. James C. Johnston is a board certified neurologist with 26 years of medical experience, and is also an attorney who serves as the director for Legal Medicine Consultants. As a medical and legal professional, Dr James C. Johnston, who received his MD from the University of Texas Health Science Center in San Antonio, Texas, has published on a number of subjects regarding medical malpractice and litigation.

He has co-authored several articles on cerebral palsy and electronic fetal monitoring (EFM), which have been published in the Journal of Child Neurology, Journal of Maternal-Fetal and Neonatal Medicine, Journal of Childhood and Developmental Disorders, and The Surgery Journal.

Electronic fetal monitoring is based on a virtually non-existent scientific foundation, has a false positive rate exceeding 99%, and has not affected the incidence of cerebral palsy or any other neonatal malady. It has, however, increased the cesarean section rate, with the expected increase in morbidity and mortality to mothers and babies.

EFM is the cardinal driver of the worldwide malpractice litigation crisis centered around cerebral palsy. In addition, the daily use of this ineffective procedure creates a ethical dilemma of extraordinary proportions, as expectant mothers are not routinely provided with informed consent regarding EFM, which is performed to protect doctors and hospitals from lawsuits.

Dr. Johnston and his co-author propose linking EFM to the Daubert exclusionary evidence doctrine to end cerebral palsy litigation, and following contemporary ethical guidelines to provide women with a choice by telling them the whole EFM story, including the emerging evidence that cesarean sections may expose babies to the risk of future chronic diseases and neuropsychiatric disorders. 

​A graduate of the University of Texas Health Science Center in San Antonio, TX, Dr. James C. Johnston has nearly three decades of experience as a neurologist. Throughout his professional career, Dr. James C. Johnston has remained an active member of various professional organizations like the American Academy of Neurology.

The American Academy of Neurology (AAN) is the world's largest professional association of neurologists, and the leading resource center for neurologists around the world. The organization was founded in 1948, and now represents more than 30,000 members. It is dedicated to promoting the highest quality patient-centered care.

The 68th AAN Annual Meeting will take place April 15-21, 2016, in Vancouver, British Columbia, Canada, where leading neurologists will discuss the latest breakthroughs in the field. There will be more than 12,000 attendees including neurologists and neuroscience specialists. Lectures, meetings and discussions will focus on common neurological problems and controversies. Additionally, there will be presentations of contemporary issues such as global health concerns. These are particularly relevant for Dr. Johnston, a Partner in Global Neurology Consultants and Director of GlobalNeuroCare.org, a 501(c)(3) charity dedicated to improving neurological care in resource limited regions.