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I. Adults and Children with Headache: Evidence-based Role of
Neuroimaging.
II.
Authors
L. Santiago Medina, MD, MPHa
Amisha Shah, MDa
Elza Vasconcellos, MDb
a
Health Outcomes, Policy and Economics (Hope) center. Division of Neuroradiology. Department of
Radiology. Miami Children's Hospital.
b
Headache Center. Department of Neurology. Miami Children's Hospital.
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KEY POINTS
A. Issues
1. Which adults with new-onset headache should undergo neuroimaging?
2. What neuroimaging approach is most appropriate in adults with new-onset of
headache?
3. What is the role of neuroimaging in adults with migraine or chronic headache?
4. What is the role of imaging in patients with headache and subarachnoid
hemorrhage suspected of having an intracranial aneurysm?
5. What is the recommended neuroimaging examination in adults with headache and
known primary neoplasm suspected of having brain metastases?
6. When is neuroimaging appropriate in children with headache?
7. What is the sensitivity and specificity of CT and MR imaging?
8. What is the cost effectiveness of neuroimaging in patients with headache?
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IV.
Key points
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In adults, benign headache disorders usually start before the age of 65 years.
Therefore, in patients older than 65 years, secondary causes should be suspected.
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Although most headaches in children are benign in nature, a small percentage is
caused by serious diseases, such as brain neoplasm.
•
CT imaging remains the initial test of choice for: (1) new-onset headache in adults
and (2) headache suggestive of subarachnoid hemorrhage (limited evidence).
•
Neuroimaging is recommended in adults with nonacute headache and unexplained
abnormal neurologic examination (moderate evidence).
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CT angiography and MR Angiography have sensitivities greater than 85% for
aneurysms greater than 5 mm. The sensitivity of these two examinations drops
significantly for aneurysms less than 5 mm (moderate evidence).
•
In adults with headache and known primary neoplasm suspected of having brain
metastatic disease, MR imaging with contrast is the neuroimaging study of choice
(moderate evidence).
•
Neuroimaging is recommended in children with headache and an abnormal
neurologic examination or seizures (moderate evidence).
•
Sensitivity and specificity of MR imaging is greater than CT for intracranial lesions.
For intracranial surgical space-occupying lesions, however, there is no difference in
diagnostic performance between MR imaging and a CT (limited evidence).
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Issues
Issue 1: Which adults with new-onset headache should undergo neuroimaging?
Summary of Evidence
The most common causes of secondary headache in adults are brain neoplasms,
aneurysms, arteriovenous malformations, intracranial infections, and sinus disease.
Several history and physical examination findings may increase the yield of the
diagnostic study discovering an intracranial space-occupying lesion in adults. Table 2
shows the scenarios that should warrant further diagnostic testing (limited evidence). The
factors outlined in Table 2 increase the pretest probability of finding a secondary
headache disorder.
Issue 2: What neuroimaging approach is most appropriate in adults with new-onset
of headache?
Summary of Evidence
The data reviewed demonstrate that 11% to 21% of patients presenting with new-onset
headache have serious intracranial pathology (moderate and limited evidence)
CT examination has been the standard of care for the initial evaluation of new-onset
headache because CT is faster, more readily available, less costly than MR imaging, and
less invasive than lumber puncture. In addition, CT has a higher sensitivity than MR
imaging for subarachnoid hemorrhage (SAH). Unless further data becomes available that
demonstrate higher sensitivity of MR imaging, CT study is recommended in the
assessment of all patients who present with new-onset headache (limited evidence).
Lumbar puncture is recommended in those patients in which the CT scan is nondiagnostic
and the clinical evaluation reveals abnormal neurologic findings, or in those patients in
whom SAH is strongly suspected (limited evidence). Fig. 1 shows a suggested decision
tree to evaluate adult patients with new-onset headache.
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Issue 3: What is the role of neuroimaging in adults with migraine or chronic
headaches?
Summary of Evidence
Most of the available literature (moderate and limited evidence) suggests that there is no
need for neuroimaging in patients with migraine and normal neurologic examination.
Neuroimaging is indicated in patients with nonacute headache and unexplained abnormal
neurologic examination; or in patients with atypical features or headache that does not
fulfill the definition of migraine.
Issue 4: What is the role of imaging in patients with headache and subarachnoid
hemorrhage suspected of having an intracranial aneurysm?
Summary of Evidence
In North America, 80% to 90% of nontraumatic SAH is caused by the rupture of
nontraumatic cerebral aneurysms. CT angiography and MR Angiography have sensitivities
greater than 85% for aneurysms greater than 5 mm. The sensitivity of these two
examinations drops significantly for aneurysms less than 5 mm.
Issue 5: What is the recommended neuroimaging examination in adults with
headache and known primary neoplasm suspected of having brain metastases?
Summary of Evidence
In patients older than 40 years, with known primary neoplasm, brain metastasis is a
common cause of headache. Most studies described in the literature suggest that contrastenhanced MR imaging is superior to contrast-enhanced CT in the detection of brain
metastatic disease, especially if the lesions are less than 2 cm (moderate evidence). In
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patients with suspected metastases to the central nervous system, enhanced brain MR
imaging is recommended.
Issue 6: When is neuroimaging appropriate in children with headache?
Summary of Evidence
Table 3 summarizes the neuroimaging guidelines in children with headaches. Theses
guidelines reinforce the primary importance of careful acquisition of the medical history
and performance of a thorough examination, including a detailed neurologic examination.
Among children at risk for brain lesions based on these criteria, neuroimaging with either
MR imaging or CT is valuable in combination with close clinical follow up.
Issue 7: What is the sensitivity and specificity of CT and MR imaging?
Summary of the Evidence
Sensitivity and specificity of MR imaging is greater than CT for intracranial lesions. For
surgical intracranial space-occupying lesions, however, there is no difference between
MR imaging and CT in diagnostic performance.
Issue8:What is the cost-effectiveness of neuroimaging in patients with headache?
Summary of the Evidence
No well -designed cost-effectiveness analysis (CEA) in adults could be found in the
literature. CEA in children with headache suggests that MR imaging maximizes qualityadjusted life years (QALY) gained at a reasonable cost-effectiveness ratio in patients at
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high risk of having a brain tumor. Conversely, the strategy of no imaging with close
clinical follow up is cost saving in low-risk children. Although the CT-MR imaging
strategy maximizes QALY gained in the intermediate-risk patients, its additional cost per
QALY gained is high. In children with headache, appropriate selection of patients and
diagnostic imaging strategy may maximize quality-adjusted life expectancy and decrease
costs of medical workup.
Table 2. Suggested guidelines for neuroimaging in adult patients with newonset headache
• “First or worst” headache
• Increased frequency and increased severity of headache
• New-onset headache after age 50
• New-onset headache with history of cancer or immunodeficiency
• Headache with fever, neck stiffness, and meningeal signs
• Headache with abnormal neurologic examination
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Table 3. Suggested guidelines for neuroimaging in pediatric patients with
headache.
• Persistent headaches of less than 1 month duration.
• Headache associated with abnormal neurologic examination.
• Headache associated with seizures.
• Headache with new onset of severe episodes or change in the type of
headache.
• Persistent headache without family history of migraine.
• Family or medical history of disorders that may predispose one to
CNS lesions, and clinical or laboratory findings that suggest CNS
involvement.
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Fig 1. Decision tree for use in adults with new-onset headache. For those patients who meet any of the guidelines in
Table 2, CT is suggested. For patients who do no meet these criteria or those with negative diagnostic workup,
clinical observation with periodic reassessment is recommended. If CT is positive, further workup with CT
angiography or MR imaging plus MR angiography is recommended. In selected case, conventional angiography and
endovascular treatment may be warranted. If CT is negative, lumbar puncture is advised. In patients with suspected
metastatic brain disease, contrast-enhanced MR imaging is recommended. In patients with suspected intracranial
aneurysm, further assessment with CT angiography or MR angiography is warranted. Abbreviations: CTA, CT
angiography; LP, lumbar puncture; MRA, MR angiography; MRI, MR imaging. From LS Medina et al. Adults and
Children with headache: Evidence-Based Diagnostic Evaluation. Neuroimag Clin N Am 13 (2003) 225-235 with
permission.
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