Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

The use of neuroimaging as part of the initial workup in the emergency department (ED) for patients with atraumatic headache is increasing, whereas the proportion of cases in which clinically significant intracranial pathology is detected is decreasing. In the last few decades, the exposure to medical ionized radiation from utilization of computer tomography (CT) increased dramatically, raising concern about radiation-induced cancer. Different guidelines were suggested to address the role of neuroimaging in the investigation of adult patients presenting to the ED with nontraumatic headache.

We retrospectively evaluated data from all consecutive patients who underwent a head CT in the ED for the evaluation of headache during 2015. Patients were included only if a normal neurologic examination was documented.

In total, 422 patients were included. About 43.4% of scans were normal. Most abnormal findings were sinusitis (148 patients, 35%) or ischemic changes. Seven CT scans (1.6%) showed clinically significant findings requiring an immediate change in management.

A normal neurologic examination, even when performed by a neurologist, does not rule out a significant secondary cause for headache. A CT scan in the ED is indicated for patients presenting with severe nonremitting headache who never had neuroimaging in the past.