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Diagnostic testing for the evaluation of headaches

R W Evans1

  • 1Department of Neurology, University of Texas, Houston Medical School, USA.

Neurologic Clinics
|February 1, 1996
PubMed
Summary

Neuroimaging rarely reveals serious pathology in patients with typical headaches or migraines, even with a normal neurological exam. However, "first or worst" headaches require prompt evaluation for subarachnoid hemorrhage, as CT scan sensitivity decreases rapidly post-ictus.

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Area of Science:

  • Neurology
  • Radiology
  • Diagnostic Imaging

Background:

  • Headaches are a common neurological symptom with over 300 potential causes.
  • Neuroimaging is often considered for headaches due to medical indications, patient anxiety, and medico-legal reasons.
  • The diagnostic yield of neuroimaging in patients with headaches and normal neurological examinations is generally low.

Purpose of the Study:

  • To evaluate the utility of neuroimaging in the diagnosis of various headache types.
  • To determine the prevalence of specific pathologies detected via neuroimaging in headache patients.
  • To assess the diagnostic yield of neuroimaging for migraines and "first or worst" headaches.

Main Methods:

  • Meta-analysis of multiple studies on neuroimaging in headache patients.
  • Compilation of data from over 3000 scans for general headache evaluation.
  • Analysis of over 1400 scans specifically for migraine patients.

Main Results:

  • Pathologies like tumors, AVMs, hydrocephalus, aneurysms, subdural hematomas, and strokes are found in a small percentage of patients with normal neurological exams.
  • Neuroimaging yields are particularly low for migraine patients, with rare detection of tumors, AVMs, or aneurysms.
  • White matter abnormalities (WMA) are frequently reported in migraine patients on MRI, though their cause is uncertain.

Conclusions:

  • Routine neuroimaging is not highly beneficial for patients with typical headaches or migraines and normal neurological exams.
  • "First or worst" headaches necessitate urgent evaluation for subarachnoid hemorrhage, with imaging sensitivity decreasing over time.
  • While rare, serious conditions like hematomas or strokes can occur after head injury or in older patients, warranting appropriate imaging.

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