Michael Eller; Peter J Goadsby

Disclosures

Expert Rev Neurother. 2013;13(3):263-273. 

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Expert Commentary

There are several guidelines that address the question of imaging in common headache. An American Academy of Neurology practice parameter[37] and a contemporaneous guideline for use in the primary care setting were published in 2000.[101] Evidence-based conclusions were drawn from a meta-analysis performed on a series of smaller studies, which suffered many similar methodological flaws as those outlined above. Level B evidence was found for the following recommendation: "Neuroimaging is not usually warranted in patients with migraine and a normal physical examination". Further, in relation to neuroimaging for nonacute headache, there were no evidence-based recommendations regarding: "TTH (grade C)" and "[The] relative sensitivity for MRI as compared with CT in the evaluation of migraine or other nonacute headache". Caveats are provided where imaging should be considered – these 'red flags' are considered below.[37] In England (UK), NIH guidelines only recommend imaging if there are red flags present; specialist referral is recommended if there is new headache, present for at least 1 month, without other concerning symptoms.[102]

Hence guidelines do not mandate imaging in common headache, assuming an absence of warning symptoms and a normal physical examination. If a patient requests a scan, it may be reasonable to organize this electively, providing one has appraised them of the possibility of an incidental finding that will have no import to their treatment yet be stuck on their medical record forever. In the 21st century, this should be an MRI where possible. This modality is more sensitive to intracranial abnormalities[38] and has no associated radiation risk, which can become substantial in patients serially imaged over years. Particularly, is also safer in women of child-bearing age – the most common demographic seen with headache – who have a higher cancer risk on exposure to ionizing radiation, as well as the attendant risks of an unknown pregnancy.[39]

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