Headache Medicine 2021, 12(4):283-286 p-ISSN 2178-7468, e-ISSN 2763-6178

283

ASAA

DOI: 10.48208/HeadacheMed.2021.46

Headache Medicine

Review

Tips on when to request an imaging assessment (RMI, CT, or

angiography) in a patient suffering from a headache

Maria de Fátima Viana Vasco Aragão

, Luziany Carvalho Araújo

, Marcelo Moraes Valença

Federal University of Pernambuco, Recife, Pernambuco, Brazil

Hospital da Restauração, Recife, Pernambuco, Brazil.

Abstract

This article is a mini-narrative review covering practical aspects of when to request an

imaging evaluation of a headache patient. The vast majority of patients who seek help in

a medical ofce receive as a diagnostic hypothesis one of the primary headaches, such

as migraine, tension-type headache, or cluster headache. The vast majority of patients

who arrive with a headache at the neurologist's ofce are migraineurs; individuals who

suffer from tension-type headaches rarely seek the neurologist's help. In the emergency

scenario, there is a more signicant occurrence of secondary headaches when compared

to patients treated in an outpatient clinic. In evaluating a patient with a headache, the

physician should pay attention to red ags or signs that may indicate a secondary cause

for the pain the patient reports. In primary headaches, with the exception of trigeminal

autonomic cephalalgias, there is no need to investigate by imaging. In cluster headache,

in some cases, intracranial lesions may be found as the cause, mainly parasellar lesions

such as cerebral aneurysms. Thus, image evaluation is indicated. Depending on the

diagnostic suspicion in secondary headaches, different imaging examinations should be

requested, the most frequent being MRI, CT, and angiography.

Maria de Fátima Viana Vasco Aragão

fatima.vascoaragao@gmail.com

Edited by:

Juliana Ramos de Andrade

Keywords:

Headache

Magnetic Resonance Imaging

Tomography

X-Ray Computed

Migraine Disorders

Cluster Headache

Red ags

Received: November 12, 2021

Accepted: December 5, 2021

284

ASAA

Aragão MFVV, Araújo LC, Valença MM

Tips on when to request an imaging assessment (RMI, CT, or angiography) in a patient suffering from a headache

Introduction

eadache is one of the most frequent symptoms or com-

plaints, and in some situations it should be considered

a warning sign, since it can express serious problems for

several causes.

1-4

The rst classication of headaches was made in 1988

and modied in 2004 by the

International Classication

of Headache Disorders

second edition

(ICHD-2). The

diagnosis is currently based on criteria updated in 2018,

published as ICHD-3. The classication of headaches is

clinically useful because it standardises the nomenclature of

the different types and subtypes of headaches, scientically

assisting in the diagnosis, prognosis and more accurate

and uniform treatment.

Headaches are classied in three groups: (1) Primary

Headaches; (2) Secondary Headaches; and (3) Painful

cranial neuropathies, other facial pain, and other

headaches.

Doctors are regularly faced with the question of whether or

not imaging evaluations are necessary to conrm or clarify

the cause of a headache.

In addition, many patients

come to the consulting room afraid they are suffering from

a serious illness and, therefore, ask the doctor to request

a CT of an MRI, sometimes unnecessarily.

1-3

Considering

the cost-benet,

1-3

radiation protection and adverse effects

(mainly from iodinated contrast), and cumulative (in

relation to gadolinium), it is difcult to justify performing

the imaging exam without clinical evidence that in the case

in question the examination is indicated.

1-3

It was observed that there are no changes in imaging tests

in most cases in which they were performed in patients with

headache, especially when there are no other associated

neurological symptoms.

1,3,5

So, considering cost-benet,

how to identify which patient with a headache needs and

will benet from an imaging exam?

Criteria to identify which patients with headache need and

will benefit from an image exam

In order to make a responsible clinical and economic

decision, it is important to differentiate between a primary

headache (where the patient has no underlying organic

brain abnormality as a cause of the primary headache)

and secondary headaches (which are often associated

with organic brain disease).

1-3

The clinical features that alert for the diagnosis of

secondary headache and that should lead to an imaging

exam are

1-3

• Headache that reaches high peak intensity in less than

ve minutes;

• New type of headache;

• Change in the pattern of a previously stable headache;

• Headache that changes with posture, for example if the

patient is in an upright position;

• Headache that awakens the patient;

• Headache triggered by physical activity or Valsalva

maneuver (e.g., coughing, laughing);

• Onset after 50 years of age;

• Presence of neurological symptoms and/or signs;

• A history of recent trauma;

• High temperature;

• History of malignancy or HIV;

• Epileptic seizures;

• Active infections.

Neuroimaging ndings are important to dene the

possibility of performing lumbar puncture to assess the

presence of blood, infection and cellular abnormalities in

the cerebrospinal uid, without risk to the patient, as it

serves to identify the existence of an expansive lesion and

hydrocephalus that would contraindicate the puncture due

to the risk of herniation of the cerebellar tonsils and other

brain structures.

1-3

Primary and Secondary Headaches

Primary Headaches

The diagnosis of primary headache is clinical. One is

dealing with a “chronic, repetitive headache,” without

any medical condition being detected as a cause. It is

classied by the prole of symptoms, being a benign

entity, of mild to severe intensity, not representing a risk to

life.

1-3

The most frequent types are:

• Tension-type headache – it is the most frequent type,

affecting 60-78% of the population

lasting from minutes

to days; the pain is typically bilateral, “squeezing” or

“pressing”, from mild to moderate intensity; lacking nausea,

but may happen with photophobia and phonophobia,

predominantly in males.

• Migraine – is the second most frequent type; chronic

neurological disease, with a prevalence of 15% dened

285

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Aragão MFVV, Araújo LC, Valença MM

Tips on when to request an imaging assessment (RMI, CT, or angiography) in a patient suffering from a headache

as an abnormal neurovascular reaction, which occurs in a

genetically vulnerable organism; more frequent in the female

sex. It is characterised by recurrent episodes of pulsatile

headache, uni- or bilateral, with associated manifestations

such as nausea, vomiting, photophobia, phonophobia and

osmophobia, visual disturbances, and drowsiness.

Very

often, it can be associated with triggering factors, such

as sleep disturbances, alcohol consumption, fatty or spicy

foods, stress, great physical exertion, etc.

Despite being a primary headache, some imaging studies

have shown, however, that there is a higher frequency of

hyperintensity foci in FLAIR and T2 in brain white matter.

6,7

It was also observed that stroke occurs more frequently in

patients with aura (8% of subclinical cerebellar infarctions).

A retrospective study showed that patients with migraine

with aura may have hypoperfusion in only one of the

cerebellar hemispheres, or that this hypoperfusion may

be associated with a reduction in contralateral cerebral

cortical perfusion. (crossed cerebellar diaschisis).

Other studies show regional hyperperfusion in the

affected cerebral cortex, corresponding to neurological

manifestations during the aura.

• Cluster headache – it is the least frequent, 0.2% to 3%

being, also, of the neurovascular type. Some ndings

suggest that its origin may be in the hypothalamus. Despite

being a primary headache, an investigation by MRI is

recommended because patients with para-sellar lesions

open the picture with a headache that fullls the criteria

for cluster headache.

Secondary Headaches

Secondary headaches are usually due to an underlying

disease, which can be primary from the central nervous

system or from other organs, such as sinus infections,

pneumonia, etc.

1-3

Headaches caused by disorders of the central nervous

system are more acute, of recent onset, often accompanied

by vomiting, visual disturbances (double vision, blurred

vision), motor and/or sensory decits in the limbs, epileptic

seizures, language disorders, and changes in the level

of consciousness. The most frequent causes of secondary

headaches are infections, vascular, trauma and tumors.

Final Considerations

The majority of patients with headaches who go to

emergency services generally respond well to the therapy

used, with no need for imaging evaluation. If the headache

presents atypical features, the neurologic examination

is abnormal, and/or the patient does not respond to

conventional therapy, the possibility of a secondary

headache should be investigated and imaging studies

indicated.

Below we summarise the most indicated exams according

to the recommendation of the

American College of

Radiology

(ACR, 2019):

• Sudden, severe headache (worst headache of life): CT

without venous contrast, with the use of contrast-enhanced

computed tomography angiography in all these patients

being controversial.

• New headache associated with papilledema: MRI with

and without venous contrast or MRI without contrast or CT

without contrast.

• Post-traumatic headache: CT without contrast.

• New or progressive headache with warning signs (e.g.,

physical exertion, neurological decit, known or suspected

cancer, immunosuppression, ≥50 years of age): CT

without contrast or MRI with and without venous contrast

or MRI without contrast.

• Headache of suspected trigeminal autonomic origin:

MRI with and without venous contrast.

• Chronic headache with new associated ndings or

increased frequency: MRI with and without venous contrast

or MRI without contrast.

• Migraine, tension-type headache, and chronic headache

with no other associated ndings: no imaging evaluation

required.

Acknowledgment

The authors thank Dr. Maria de Fátima Griz and Dr.

Suzana Serra for their important suggestions with regard

to this article.

Funding: No nancial support

Conflict of Interest: No

Contribution´s of authors: The authors' participation in the

construction of the manuscript was equal.

Maria de Fátima Viana Vasco Aragão

https://orcid.org/0000-0002-2341-1422

Luziany Carvalho Araújo

https://orcid.org/0000-0001-5072-8487

Marcelo Moraes Valença

https://orcid.org/0000-0003-0678-3782

286

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Aragão MFVV, Araújo LC, Valença MM

Tips on when to request an imaging assessment (RMI, CT, or angiography) in a patient suffering from a headache

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