Is neuroimaging mandatory for headache

Is neuroimaging mandatory for headache

Most patients do not need neuroimaging. Again, 90% of patients have primary headaches with a diagnosis made by a detailed history and normal neurologic examination. 

Neuroimaging should be considered for those patients whose temporal and headaches features include the below points:

(1) the “first or worst” headache

(2) subacute headaches with increasing frequency or severity

(3) a progressive or new daily persistent headache

(4) chronic daily headache

(5) headaches always on the same side

(6) headaches not responding to treatment

(7) headaches triggered by cough, exertion, or Valsalva manuever.

Patient demographics and comorbidities that should prompt consideration of neuroimaging include headaches cooccurring with seizures, a history of cancer or immunosuppression (human immunodeficiency virus [HIV]-infected or iatrogenically immunosuppressed), pregnancy or the postpartum period, and new-onset headache in those over 50 years of age.

Worrisome associated symptoms and signs prompting neuroimaging include headaches associated with fever, stiff neck, nausea, and vomiting, headaches other than migraine with aura associated with focal neurologic symptoms or signs, and headaches associated with papilledema, cognitive impairment, or personality change.

The likelihood that either computed tomography (CT) or magnetic resonance imaging (MRI) will reveal an abnormality responsible for the headache in patients with any headache and a normal neurologic examination is approximately 2%. 

Here is a mnemonic to help remember to “SNOOP for the red flags.”

SNOOP: Red Flags to Consider Neuroimaging for Headaches

• Systemic symptoms (fever, weight loss) or
• Secondary headache risk factors (HIV, systemic cancer, pregnancy and postpartum)
• Neurologic symptoms or abnormal signs (confusion, impaired alertness, or consciousness)
• Onset: sudden, abrupt, or split-second-thunderclap
• Older: new onset and progressive headache, especially in age >50 years (e.g., giant cell arteritis)
• Previous headache history or headache progression: first headache or different (change in attack frequency, severity, or clinical features)