What are the Recommendations for Neuromaging Because of Headaches?

Patient Presentation
A teenage male came to clinic with a history consistent with the diagnosis of new onset migraine headache with visual aura. Although several family members had common migraine headaches none had aura and this distressed both the patient and family members. The family wanted neuroimaging but his pediatrician wasn’t sure which modality to order. His pediatrician asked a colleague if she knew what the guidelines for neuroimaging were. The colleague did a search of the National Guidelines Clearinghouse and found two guidelines. After review and discussion with the family the pediatrician did not want to order imaging and the family was very unhappy with this. The teenager was seen the next day in a local emergency room where a magnetic resonance imaging (MRI) examination of his head was normal.

Discussion
Headaches are not only painful but can significantly affect the lives of patients and families. Education and support for patients is key to managing headaches. Detailed diaries not only help with initial diagnosis but also chronic management.

Common headache types include:

  • Tension headache
    • Location – bilateral
    • Intensity – mild or moderate
    • Description – non-pulsating tightening or pressure
    • Activities – not aggravated by usual activities
    • Duration – 30 minutes – continuous
    • Frequency – 15 days per month for more than 3 months for chronic tension headache
    • Treatment – acute – analgesics, chronic – acupuncture
  • Migraine with aura (classic migraine)
    • Location – uni- or bilateral
    • Intensity – moderate or severe
    • Description – pulsating, banging or throbbing
    • Activities – aggravated by usual activities, may cause people to avoid usual activities
    • Duration – 1-72 hours in teens, 4-72 hours in adults, symptoms develop gradually over at least 5 minutes and all symptoms are fully reversible.
    • Frequency – 15 days per month for more than 3 months for chronic migraine
    • Miscellaneous – the aura can occur with or without the headache, occurs with sensory sensitivity including including visual (i.e. flicking lights, spots, partial visual loss), sounds (hyperacousis), touch (i.e. numbness, tingling, pins and needles), speech (i.e. speech disturbance or loss), nausea and emesis also occur
    • Treatment – acute – analgesics, triptans, sleep, prophylaxis – propanolol, toprimate, gabpentin, acupuncture, riboflavin
  • Migraine without aura (common migraine)
    • Location – uni- or bilateral
    • Intensity – moderate or severe
    • Description – pulsating, banging or throbbing
    • Activities – aggravated by usual activities, may cause people to avoid usual activities
    • Duration – 1-72 hours in teens, 4-72 hours in adults,
    • Frequency – 15 days per month for more than 3 months for chronic migraine
    • Miscellaneous – often has nausea, emesis, and may have sensitivity to sound and light
    • Treatment – acute – analgesics, triptans, sleep, prophylaxis – propanolol, toprimate, gabpentin, acupuncture
  • Cluster headache
    • Location – unilateral usually around eye
    • Intensity – severe to very severe
    • Description – variable descriptions include boring, burning, sharp, throbbing or tightening
    • Activities – agitated
    • Duration – 15 minutes – 3 hours
    • Frequency – 1 every other day to 8 per day with remission between episodes of > 1 month for episodic cluster headache, 1 every other day to 8 per day with remission between episodes of < 1 month in a 12 month period for chronic cluster headache
    • Miscellaneous – on same side as headache eye changes (red/watery eye, constricted pupil, swollen or drooping lid,) nose changes (i.e. rhinitis) or facial changes (i.e. facial swelling)
    • Treatment – acute – oxygen and triptan, prophylaxis – verapamil
  • Medication overuse
    • Location – uni or bilateral
    • Intensity – mild to severe
    • Description – non-pulsating tightening or pressure
    • Activities – not aggravated by usual activities
    • Duration – 30 minutes to continuous
    • Frequency – almost daily
    • Miscellaneous – common history is headache began or worsened while taking various medication for more than 3 months including analgesics, triptans, opiods, ergots or combinations of them. As the treatment is withdrawal (acute not gradual is recommended) headache will usually get worse before better.

Treatment depends on many factors and those listed above may or may not be appropriate for different ages and specific patients.

Learning Point
Neuroimaging is not recommended for most types of headaches. The National Clinical Guideline Center in the United Kingdom states: “Do not refer people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache for neuroimaging solely for reassurance.” The first episode of cluster headache may warrant imaging but discussion with a neurologist or other headache specialist is recommended.

American College of Radiology Appropriateness Criteria for headache in a child includes the following recommendations:

1. Primary headache including tension headache, migraine with and without aura, and cluster headache

For those headaches that the patient has no neurological findings or signs of increased intracranial pressure, the patient is normal in between headaches with return to baseline status, and patient is not having progression of headache, then no neuroimaging is recommended. The guideline specifically states: “no imaging is indicated for typical migraine.” For other variations of primary headache such as ophthalmological migraine with focal neurological signs, confusional migraine, progressive chronic headache, hemiplegic migraine, patients with seizures and postictal headache then MRI is recommended. For secondary headaches without neurological symptoms such as referred pain from other structures, metabolic abnormalities, medication withdrawal headache, etc., neuroimaging is not recommended.

2. Headache with positive neurological signs or signs of increased intracranial pressures

If there is a concern for brain tumor then MRI of the brain with and without contrast is recommended. If cranial infection is suspected, CT is recommended for possible meningitis or encephalitis before performing lumbar puncture. Depending on pathology suspected and previous imaging other imaging modalities may be indicated. If trauma is suspected then CT or MRI should be considered.

3. Abrupt onset of high intensity headache (thunderclap) suggesting vascular rupture

For thunderclap headache – CT without contrast is recommended. If there is a first degree relative with known vascular pathology, MRI or MRA is recommended. Depending on pathology suspected and previous imaging, other imaging modalities may also be indicated.

Questions for Further Discussion
1. What are indications for referral to a neurologist for headaches?
2. What are indications for consultation with a radiologist?

Related Cases

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com, the National Guideline Clearinghouse and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Headache, CT Scans and MRI Scans.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check You Tube Videos.

Hayes LL, Coley BD, Karmazyn B, Dempsey-Robertson ME, Dillman JR, Dory CE, Garber M, Keller MS, Kulkarni AV, Meyer JS, Milla SS, Myseros JS, Paidas C, Raske ME, Rigsby CK, Strouse PJ, Wootton-Gorges SL, Expert Panel on Pediatric Imaging. ACR Appropriateness Criteria headache – child. [online publication]. Reston (VA): American College of Radiology (ACR); 2012. 8 p. [41 references]

National Clinical Guideline Centre. Headaches: diagnosis and management of headaches in young people and adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2012 Sep. 38 p.(Clinical guideline; no. 150). 

ACGME Competencies Highlighted by Case

  • Patient Care
    1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
    2. Essential and accurate information about the patients’ is gathered.
    3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
    4. Patient management plans are developed and carried out.
    5. Patients and their families are counseled and educated.
    6. Information technology to support patient care decisions and patient education is used.
    7. All medical and invasive procedures considered essential for the area of practice are competently performed.
    8. Health care services aimed at preventing health problems or maintaining health are provided.
    9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.

  • Medical Knowledge
    10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
    11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.

  • Practice Based Learning and Improvement
    12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
    13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
    14. Knowledge of study designs and statistical methods to appraisal clinical studies and other information on diagnostic and therapeutic effectiveness is applied.
    15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.

  • Professionalism
    21. A commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices are demonstrated.

  • Systems Based Practice
    23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
    24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.

    Author

    Donna M. D’Alessandro, MD
    Professor of Pediatrics, University of Iowa Children’s Hospital