Is Head Computerized Tomography Indicated for the Workup of Headache in Patients with Intact Neurological Examination

Abstract

Introduction: The use of neuroimaging as part of the initial workup in the emergency department (ED) for patients with atraumatic headache is increasing, whereas the proportion of cases in which clinically significant intracranial pathology is detected is decreasing. In the last few decades, the exposure to medical ionized radiation from utilization of computer tomography (CT) increased dramatically, raising concern about radiation-induced cancer. Different guidelines were suggested to address the role of neuroimaging in the investigation of adult patients presenting to the ED with nontraumatic headache. Materials and Methods: We retrospectively evaluated data from all consecutive patients who underwent a head CT in the ED for the evaluation of headache during 2015. Patients were included only if a normal neurologic examination was documented. Results: In total, 422 patients were included. About 43.4% of scans were normal. Most abnormal findings were sinusitis (148 patients, 35%) or ischemic changes. Seven CT scans (1.6%) showed clinically significant findings requiring an immediate change in management. Conclusion: A normal neurologic examination, even when performed by a neurologist, does not rule out a significant secondary cause for headache. A CT scan in the ED is indicated for patients presenting with severe nonremitting headache who never had neuroimaging in the past.

Headache Characteristics in the Neurological Emergency Department: A Retrospective Study

“…Typical "red flags" in the clarification of headaches are patient age over 50 years, immunosuppression, an abnormal neurological examination finding or additional symptoms such as fever. However, a study by Goldstein et al 2018 also showed that a normal neurological finding in patients with headaches does not rule out a secondary headache and pathological brain imaging findings (17). The care of patients with headache in the ED represents a challenging and cost-intensive task, especially in times of increasing demand by patients (18,19).…”

Increasing and disparate use of neuroimaging for adults and children with non‐traumatic headaches in the US emergency departments: Opportunities for improvement

“…[17][18][19] In the last two decades, overall imaging utilization, regardless of indication, has been on the rise in the United States, 20 including both the adult and pediatric ED settings [21][22][23][24] with up to 30.0% of currently performed medical imaging of dubious clinical necessity. 23,25,26 The scope and focus of prior studies investigating the use of imaging in headache were limited to outpatient settings, 1,27 ED settings before 2007, 23,28 single-institution cohorts, 6 short (1 year) study periods, 6,29 and single imaging modality, 29 or were based on patient-generated data obtained through household surveys. 22 Longitudinal population-level patterns of imaging utilization for headache in US EDs in the last decade remain unknown.…”