Podcast #187 - Who with a Headache Needs Imaging?

Patients present with headaches frequently, but they do not all need imaging.  However, the question becomes who does need the imaging?  The American College of Radiology updated their guidelines from the ones previously made in 2014 and we provide a rapid review in this post.

​You can read the entire ACR Appropriateness Criteria® Headache​ guidelines here at the Journal of the American College of Radiology.

While headaches are common, most cases are benign and idiopathic.  They will resolve spontaneously or with minor therapeutic measures.  There are certain exceptions though which will be covered in this post such as those with headaches that are severe and sudden onset, optic disc edema, “red flags,” migraine or tension-type, trigeminal autonomic origin, and chronic headaches with and without new or progressive features.

• Thunderclap headache
  • CT imaging of the head (CTH) without contrast remains the most common and appropriate.
  • CT arteriogram may be appropriate in certain circumstances (primarily two or more first degree family members with history of SAHs).
  • The Ottawa Subarachnoid Hemorrhage (SAH) Rule has been validated and The SGEM has covered the original study and its most recent validation well.
  • You can also learn more about the Ottawa SAH Rule by going to MDCalc.
  • There is also the helpful graphic above from this paper.
• New headache with optic disc edema
  • Magnetic resonance imaging of the brain (MRIB) with or without contrast or CTH without contrast are usually appropriate.
  • CTH with contrast and CT or MR venography may be appropriate.
• New or progressive headache with red flags
  • Red flags include subacute head trauma, related activity or event (sexual activity, exertion, position), neurological deficit, known or suspected cancer, immunosuppressed or immunocompromised state, currently pregnant, or 50 years of age or older.
  • Obtain CTH without contrast or MRIB with or without contrast.
• New primary headache of suspected trigeminal autonomic origin
  • This includes cluster headaches which are the most common form.
  • MRIB with contrast is recommended.
• Chronic headache with new features or progression
  • MRIB with or without contrast is appropriate.
  • CTH with or without contrast may be appropriate.
• Newly diagnosed migraine or tension-type headache with normal neurological exam
  • Imaging is not appropriate.
  • MRI has been studied without significant demonstrated benefit.
• Chronic stable headache with no neurologic deficit
  • Imaging is not appropriate.
  • Many studies have been done without demonstrated definite benefit.

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