Imaging results in a consecutive series of 530 new patients in the Birmingham Headache Service

Abstract

Guidelines recommend imaging only headache patients with sinister features in the history or on examination. We prospectively collected data on imaging newly presenting patients to a UK headache service. CT and MRI results were classified as normal or showing an insignificant or significant abnormality. Over 5 years, 3,655 new patients (69% female; mean age 42.0 years) with headache disorders were seen. Five hundred thirty (14.5%) underwent imaging with large differences in the proportion referred by each consultant. There were more insignificant abnormalities on MRI (46%) than CT (28%). There were 11 significantly abnormal results (2.1% of those imaged). Significant abnormalities were found in patients diagnosed with migraine in 1.2% and in 0.9% of those with tension-type headache. Significant abnormalities in those suspected to have an intracranial abnormality occurred in 5.5%. This supports the practice of selecting patients with suspicious findings for imaging, rather than imaging all patients.

Headache neuroimaging: Routine testing when guidelines recommend against them

“…(2) Neuroimaging is commonly ordered despite the fact that the yield of significant abnormalities in patients with migraines and chronic headaches is comparable to that seen in healthy research volunteers. (3–6) As a result, the American Academy of Neurology (AAN) (migraines), European Federation of Neurological Societies (EFNS) (migraines), and American Academy of Radiology (ACR) (chronic uncomplicated headaches) have all released guidelines recommending against routine neuroimaging. (7–10) Furthermore, the Choosing Wisely campaign, an initiative to stimulate dialog about potentially unnecessary tests, has specifically identified neuroimaging in headache patients as a target (www.choosingwisely.org).…”

Why do GPs with a special interest in headache investigate headache presentations with neuroradiology and what do they find?

“…30.16% of patients were investigated. This compares to rates of between 1.2 and 5.3%, where GPs have direct access to neuroradiology investigation [14–18] and up to 60% rates reported to the neurologists [16]. …”

“…15 (5.6%) of the investigated patients showed positive findings, although of those only 5 (1.9%) were felt to be of clinical significance. When GPs have access to investigation, significant abnormalities rates are reported between 2.4 and 1.4% [21] and in secondary care when investigation is clinically selective the yield is 2.1% [16, 22]. …”

“…For example, in secondary care, patients often anticipate the exclusion of secondary pathology and consultants are under pressure to make a diagnosis at the first appointment. These factors result in a wide range of investigation patterns in secondary care with headache investigation rates of up to 60% [16]. …”

Headaches and Neuroimaging

“…However, the yield of significant abnormalities on neuroimaging in patients with chronic headaches is 1–3%. 1–3 Given the comparable yield in patients without headaches, multiple guidelines have recommended against routine headache neuroimaging, 4–6 and efforts to improve the efficiency of health care utilization, such as the Choosing Wisely campaign, have identified these tests as a target. However, little is known about recent headache neuroimaging utilization, associated expenditures, and temporal trends in the United States.…”