Neuroimaging for Migraine: The American Headache Society Systematic Review and Evidence‐Based Guideline

Abstract

Objective.-To provide updated evidence-based recommendations about when to obtain neuroimaging in patients with migraine.Methods.-Articles were included in the systematic review if they studied adults 18 and over who were seeking outpatient treatment for any type of migraine and who underwent neuroimaging (MRI or CT). Medline, Web of Science, and Cochrane Clinical Trials were searched from 1973 to August 31, 2018. Reviewers identified studies, extracted data, and assessed the quality of the evidence in duplicate. We assessed study quality using the Newcastle-Ottawa Scale.Results.-The initial search yielded 2269 publications. Twenty three articles met inclusion criteria and were included in the final review. The majority of studies were retrospective cohort or cross-sectional studies. There were 4 prospective observational studies. Ten studies evaluated the utility of CT only, 9 MRI only, and 4 evaluated both. Common abnormalities included chronic ischemia or atrophy with CT and MRI scanning, and non-specific white matter lesions with MRI. Clinically meaningful abnormalities requiring intervention were relatively rare. Clinically significant neuroimaging abnormalities in patients with headaches consistent with migraine without atypical features or red flags appeared no more common than in the general population.Recommendations.-There is no necessity to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination, and there are no atypical features or red flags present. Grade A Neuroimaging may be considered for presumed migraine for the following reasons: unusual, prolonged, or persistent aura; increasing frequency, severity, or change in clinical features, first or worst migraine, migraine with brainstem aura, migraine with confusion, migraine with motor manifestations (hemiplegic migraine), late-life migraine accompaniments, aura without headache, side-locked headache, and posttraumatic headache. Most of these are consensus based with little or no literature support. Grade C.(Headache 2020;60:318-336) OBJECTIVESThe American Headache Society (AHS) develops guidelines and practice parameters for clinicians. This guideline summarizes evidence from the existing literature about when to recommend neuroimaging in patients with migraine. We specifically reviewed Headache Maximum scores: Selection = 5, Comparability = 2, Outcome = 3, Total Quality Score = 10.

Migraine and Ischemic Stroke in Women. A Narrative Review

“…The growing body of knowledge regarding MWA and its relationship to stroke suggests that patients with aura should be carefully evaluated with an eye toward uncovering and addressing cardiovascular comorbidities, which increase stroke risk and impact choice of acute and prophylactic therapy. Diagnostic neuroimaging guidelines for primary headache disorders were published by the EHF in 2015 187 and the American Headache Society (AHS) in 2020 188 . Based primarily on consensus, both guidelines suggest MRI in persons with brainstem aura and hemiplegic migraine, and in select cases (eg, abrupt onset, new onset, late onset [age >50 years], unusual aura [ie, new features, negative symptoms, very brief duration, prolonged, persistent, without headache], increasing headache/aura frequency, severity [including worst headache], side‐locked headache, change in headache features, and posttraumatic headache).…”

Quality Improvement in Neurology: Headache Quality Measurement Set

“…Finally, to exclude secondary causes of headache, clinicians may turn to neuroimaging. An existing AAN quality measure addresses imaging overuse, 26 the American College of Radiology has developed appropriateness criteria, 27 and the American Headache Society has both a Choosing Wisely statement 28 and a more specific guideline 29 . The quality of more specific neuroimaging hospital protocols for thunderclap headache presentations specifically, including communication between the managing clinician and the radiologist, may be a topic for future consideration.…”

Quality improvement in neurology

“…An existing AAN quality measure addresses imaging overuse, 26 the American College of Radiology has developed appropriateness criteria, 27 and the American Headache Society (AHS) has both a Choosing Wisely statement 28 and a more specific guideline. 29 The quality of more specific neuroimaging hospital protocols for thunderclap headache presentations specifically, including communication between the managing clinician and the radiologist, may be a topic for future consideration.…”