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Evidence summaries

Does This Patient with Headache Need Neuroimaging?

Neuroimaging appears not to be warranted in adult patients with typical migraine with or without visual aura or tension headache and normal neurological examination. Patients presenting with thunderclap headache appear to benefit from investigations regardless of associated clinical features. Level of evidence: "B"

A systematic review 1 included 11 studies with a total of 3725 subjects. Of these diagnostic accuracy studies, 3 were retrospective cohort studies.The included studies evaluated patients with various types of nontraumatic headache. Patients were seen in out-patient, in-patient and emergency department settings. Where provided, the mean age of the participants ranged from 35 to 52 years.The pooled prevalence of abnormality on neuroimaging ranged from 1.2% (95% CI: 0.77 to 1.8) in chronic headache to 43% (95% CI: 20 to 68) in thunderclap headache.Clinical features found to predict serious intracranial abnormality (with a pooled positive likelihood ratio (LR) statistically significantly greater than 1.0) were cluster-type headache (LR 11, 95% CI: 2.2 to 52), abnormal findings on neurologic examination (LR 5.3, 95% CI: 2.4 to 12), undefined headache (i.e. not cluster, migraine or tension type; LR 3.8, 95% CI: 2.0 to 7.1), headache with aura (LR 3.2, 95% CI: 1.6 to 6.6), headache aggravated by exertion or a valsalva-like manoeuvre (LR 2.3, 95% CI: 1.4 to 3.8), and headache with vomiting (LR 1.8, 95% CI: 1.2 to 2.6). Clinical features that were not useful in predicting serious intracranial abnormality were headache with focal symptoms, worsening of headache, male sex, quick onset headache, new onset headache, headache with nausea, increased headache severity, and migraine-type headache.Four clinical features had a pooled negative LR statistically significantly lower than one: normal neurologic examination (LR 0.71, 95% CI: 0.60 to 0.85), headache not aggravated by valsalva-like manoeuvre (LR 0.70, 95% CI: 0.56 to 0.88), absence of vomiting (LR 0.47, 95% CI: 0.29 to 0.76), and headache of defined type (LR 0.66, 95% CI: 0.44 to 0.97). However, none of these LRs were low enough to be clinically useful for ruling out significant pathological conditions. No other clinical feature was useful for ruling out serious intracranial abnormality.

Comment: The quality of evidence is downgraded by inconsistency (heterogeneity in patients).

    References

    • Detsky ME, McDonald DR, Baerlocher MO et al. Does this patient with headache have a migraine or need neuroimaging? JAMA 2006;296(10):1274-83. [PubMed]

Primary/Secondary Keywords