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American Headache Society Updated Guideline On Use of Neuroimaging for Migraine

AHS consensus clarifies when clinicians should consider CT and MRI scans for patients being assessed for migraine.

Most experts agree that neuroimaging should be used sparingly and with caution when diagnosing and treating migraine. Yet, when to use and when not to use neuroimaging has long been a vexed issue. It’s not always clear when the risks of neuroimaging are justified. Those risks include increased patient anxiety, the need for further testing which can lead to findings that are not clinically significant yet add to the patient’s anxiety, and cost, which can be significant.


Recommendations concerning when to use neuroimaging to assess for migraine vary depending on the medical association or specialty issuing the guidelines. (Image: iStock: haydenbird)

The Need for Clear Migraine Imaging Guidelines

Although existing guidelines caution against overuse of imaging, physicians often feel pressure to order imaging in headache patients for reasons that range from excluding secondary conditions to pressure (real or imagined) from patients or referring physicians. In addition, recommendations concerning when to use neuroimaging with migraine vary depending on the medical association or specialty issuing the guidelines. For example, the American College of Radiology’s “Choosing Wisely” advice is simply not to order imaging for uncomplicated headaches. Neurosurgeons, on the other hand, often rely on neuroimaging of patients with non-specific symptoms as a way to diagnose brain tumors.1,2

To cut through this lack of clarify, the American Headache Society (AHS) recently released an updated, evidence-based guideline.

 for neuroimaging in patients with migraine. The guidelines were published in the Society’s Headache journal in December 2019 based on a review and analysis of decades worth of research.

“We released guidelines over 10 years ago, and we decided with all the new things going on with imaging, it was time to update our previous guidelines,” Stephen Silberstein, MD, professor of neurology and director of the Headache Center at Thomas Jefferson University Hospital in Philadelphia, told PPM. He is one of the authors of the AHS review and guideline.

The guideline authors aimed to analyze the evidence for the “diagnostic utility … of neuroimaging (MRI and CT) in adult patients seeking outpatient treatment for episodic migraine, chronic migraine, progressive migraine, migraine with aura, and migraine without aura.”1 Their results were unequivocal: It is not necessary to neuroimage patients with migraine with no atypical features and no red flags.

Review Methods

The new guideline is based on a review of databases (eg, PubMed, Web of Science, and Cochrane Central Register of Controlled Trials) with inclusion criteria of adults age 18 years and older who sought outpatient treatment and were undergoing MRI or CT imaging. The search produced an initial set of 2,269 papers. Eighty-five were selected for further screening, and a final 23 articles were included in the review. The majority of the studies were retrospective cohort studies or cross-sectional studies.

Although the review represented a wide variety of approaches and results, the guideline authors found that the quality of the studies was “generally poor” and pointed out the need for more and higher quality research. “There were no controlled trials where people who have a migraine headache are prospectively given imaging to see what happens, compared to controls that don’t have migraine,” said Silberstein.

When to Use Imaging for Migraine: A Few Determinations

Nonetheless, the authors found the evidence to be mostly consistent and convincing. “Study subjects with concerning clinical or exam features frequently have abnormalities which require attention and should be imaged,” the authors wrote. Neuroimaging may be considered for a variety of atypical situations, such as migraine with confusion, hemiplegic migraine, migraine with brain-stem aura, post-traumatic headache, or a change in clinical features (see summary above).

On the other hand, the AHS team found no evidence to support routine neuroimaging of patients with migraine with no atypical features or red flags (including fever, papilledema, immunosuppression, or pregnancy). In these cases, the authors stated, “There is no evidence that routine imaging … is more likely to reveal meaningful abnormalities compared to the general health population in the absences of worrisome features.”1

Comorbidities and other considerations

The guideline authors found no indication for the routine use of gadolinium contrast imaging short of a strong reason to suspect multiple sclerosis or breast cancer. However, they did point out that some individuals with significant psychiatric co-morbidities might benefit from the reassurance of having a normal scan.


Practical Takeaways

Despite the complexities and limitations in the evidence, the results of the review were clear. “Migraine alone is not a risk factor for an abnormal MRI or CT in the absence of risk factors. [A patient with] migraine alone without anything else, has no greater chance of having imaging abnormalities than [a patient without] migraine,” Silberstein said. “So if you took 100 people off the street with no problems and a hundred people with migraine, the imaging would be the same.”

Silberstein hopes that the new guideline will persuade physicians to be more judicious in their use of neuroimaging for migraine. The updated guideline takes care of one of the more common reasons for overuse of imaging.

“I think physicians are always worried that they’ll ‘miss something’ and be sued,” he said. “If a physician has evidence-based guidelines, it will keep him from being sued.” And now physicians have those guidelines, based on decades of evidence and updated for the 21st century.

Last updated on: June 22, 2020
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