Elsevier

Neurologic Clinics

Volume 27, Issue 2, May 2009, Pages 393-415
Neurologic Clinics

Diagnostic Testing for Migraine and Other Primary Headaches

https://doi.org/10.1016/j.ncl.2008.11.009Get rights and content

Most primary headaches can be diagnosed using the history and examination. Judicious use of neuroimaging and other testing, however, is indicated to distinguish primary headaches from the many secondary causes that may share similar features. This article evaluates the reasons for diagnostic testing and the use of neuroimaging, electroencephalography, lumbar puncture, and blood testing. The use of diagnostic testing in adults and children who have headaches and a normal neurologic examination, migraine, trigeminal autonomic cephalalgias, hemicrania continua, and new daily persistent headache are reviewed.

Section snippets

Reasons for diagnostic testing

The indications for diagnostic testing are variable and neurologists must make decisions on a case-by-case basis when presented with a suspected primary headache if secondary headache is a consideration. Clinical situations where neurologists consider diagnostic testing are listed in Box 1.

There are many other reasons why neurologists recommend diagnostic testing: “our stubborn quest for diagnostic certainty;”1 faulty cognitive reasoning; the medical decision rule that it is better to impute

CT versus MRI

CT detects most abnormalities that may cause headaches. CT generally is preferred to MRI for evaluation of acute subarachnoid hemorrhage, acute head trauma, and bony abnormalties. There are several disorders, however, that may be missed on routine CT of the head, including vascular disease, neoplastic disease, cervicomedullary lesions, and infections (Box 2). MRI is more sensitive than CT in the detection of posterior fossa and cervicomedullary lesions, ischemia, white matter abnormalities

Neuroimaging Studies in Adults

The yield of abnormal neuroimaging studies in studies of patients who have headaches as the only neurologic symptom and normal neurologic examinations depends on several factors, including the duration of the headache, study design (prospective versus retrospective), who orders the scan, and the type of scan performed.25 The percentage of abnormal scans is higher when ordered by neurologists26 or a tertiary care center27 compared with primary care physicians and represents case selection bias.

Incidence of Pathology

Frishberg25 reviewed four CT scan studies,55, 56, 57, 58 four MRI scan studies,59, 60, 61, 62 and one combined MRI and CT scan study63 of 897 scans of patients who had migraine. These findings are combined with more recent reports of one CT scan study of 284 patients36 and six studies of MRI scans of 444 patients64, 65, 66, 67, 68, 69 for a total of 1625 scans of patients who had various types of migraine. Other than WMA, the studies showed no significant pathology except for four brain tumors

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