From the Journal: Unnecessary Neuroimaging for Patients with Presumed Primary Headaches

A new paper published in Headache® shows that neuroimaging is a nonessential diagnostic procedure for patients with presumed primary headache disorder.

Within the general population, headache can be caused by a primary or a secondary disorder. Health care providers rely on headache characteristics, the presence of “red flags” signs and symptoms that increase the likelihood of a secondary headache disorder, and physical and neurological examination findings to determine the level of suspicion for a secondary headache disorder. When a secondary headache disorder is suspected, neuroimaging is often used to differentiate between a primary versus secondary headache.

A primary headache disorder is not caused by a specific medical condition. Examples of this kind of disorder include migraine, tension-type headache (TTH), and cluster headache. Patients with a secondary headache disorder have another disorder that activates the pain-sensitive nerves of the head. Secondary headache disorders can be attributed to numerous different causes including, but not limited to, acute sinusitis, brain tumors, intracranial hemorrhage, intracranial hypertension/hypotension and systemic illnesses.

The utility of neuroimaging in patients with a presumed primary headache disorder has been investigated over the years. Most studies indicate that there is no significant difference between primary headache patients and the general population in terms of abnormal neuroimaging findings.

A recent study published in Headache®, Unnecessary Neuroimaging for Patients with Primary Headaches by Rongfei Wang, PhD, Ruozhuo Liu, PhD, Zhao Dong, PhD, Hui Su, PhD, Ran Ao, PhD, Yinglu Liu, PhD, Yan Wang, PhD, Lin Ma, PhD, and Shengyuan Yu, PhD, aimed to verify that individuals presumed to have primary headaches do not experience significant benefits from neuroimaging. In fact, the study seeked to confirm that neuroimaging is unnecessary in patients with a presumed primary headache disorder.

The study was conducted with a sample of 1,070 healthy controls and 1,070 primary headache patients. The primary headache patients were individually diagnosed using a computerized clinical decision support system (CDSS), which was created by converting summaries of diagnostic knowledge into an actionable guideline representation module. After the CDSS, patients were re-diagnosed by a headache specialist. If the diagnoses produced by the CDSS and headache specialist were inconclusive, the chief headache specialist of the project rendered a final diagnosis. The headache patients had normal neurological examinations and absence of “red flags” that would increase the suspicion for a secondary headache.

All participants in this study were assessed with either computed tomography (CT) or magnetic resonance imaging (MRI) scans without contrast. In both sample groups, 382 participants underwent CT scans and 688 underwent MRI scans, and all significant abnormalities (including tumors, hydrocephalus, vascular malformations, Chiari malformations, intracranial hemorrhages, acute infarcts) were discovered using MRI. Neuroimaging found significant abnormalities in four patients with primary headache disorders and in five healthy controls. The rate of significant abnormalities in primary headache patients in this study was 0.58%; the rate of significant abnormalities in healthy controls was 0.73%.

The study’s authors concluded that neuroimaging is unnecessary for patients with presumed primary headaches. The overuse of neuroimaging in primary headache patients can negatively contribute to patient experience. Not only can it can increase patient anxiety over the possibility of a more serious condition, such as a brain tumor or aneurysm, it can also lead to financial burden and exposure to ionizing radiation. The benefits of contrast MRI and MRA were not evaluated in this study.

The American Headache Society is committed to keeping its members up to date on the most innovative and meaningful advancements in the realm of headache medicine. One of many initiatives to support that mission is our publication of Headache: The Journal of Head and Face Pain, published ten times per year, which highlights the latest findings in the realm of headache medicine research. Our “From the Journal” series offers a preview of some of the groundbreaking work detailed in Headache. Enjoy access to the full catalogue of content plus a print subscription included with an American Headache Society Membership. Click here to become a member today.

Wang, R., Liu R. Dong Z., Su H., Ao R., Liu Y., Wang Y., Ma L., Yu S. (2018). Unnecessary Neuroimaging for Patients with Primary Headaches. Headache: The Journal of Face and Head Pain.

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