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Common primary and secondary headache disorders
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Headache may be caused by primary disorders, such as migraines, or secondary disorders, such as intracranial neoplasm or hemorrhage. Imaging plays an important role in differentiating between primary and secondary headache disorders. This article reviews the effectiveness of computed tomography (CT) and magnetic resonance imaging (MRI) in the evalu...
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Citations
... These were the top three reasons for the neuroimaging requests. Consistent with our study, previous studies found that even if no red flag or focal neurological abnormalities existed, doctors in the United States might offer a range of reasons, such as defensive medicine, community standard of care, concerns about professional reputation being affected, fear of litigation and sanctions, avoidance of patient dissatisfaction (such as patients insisting on perfect imaging, especially in pediatrics), and interest in proving that patient imaging is the right choice (Bishop et al., 2017;Howard, 2005;Kerr et al., 2017;Kuruvilla & Lipton, 2015;Quanliang et al., 2006;Rothberg et al., 2014;Scott, 2017;Scott & Elshaug, 2013;Sempere et al., 2005). In addition, the impact of social media, patient dissatisfaction, TA B L E 3 Reasons for suggesting neuroimaging to patients with primary headache. ...
Objective
To investigate the prevalence of neuroimaging in patients with primary headaches and the clinician‐based rationale for requesting neuroimaging in China.
Data sources and study setting
This study included patients with primary headaches admitted to hospitals and clinicians in China. We identified whether neuroimaging was requested and the types of neuroimaging conducted.
Study design
This was a cross‐sectional study, and convenience sampling was used to recruit patients with primary headaches. Clinicians were interviewed using a combination of personal in‐depth and topic‐selection group interviews to explore why doctors requested neuroimaging.
Data collection
We searched for the diagnosis of primary headache in the outpatient and inpatient systems according to the International Classification of Diseases‐10 code of patients admitted to six hospitals in three provincial capitals by 2022.We selected three public and three private hospitals with neurology specialties that treated a corresponding number of patients.
Principle findings
Among the 2263 patients recruited for this study, 1942 (89.75%) underwent neuroimaging. Of the patients, 1157 (51.13%) underwent magnetic resonance imaging (MRI), 246 (10.87%) underwent both head computed tomography (CT) and MRI, and 628 (27.75%) underwent CT. Fifteen of the 16 interviewed clinicians did not issue a neuroimaging request for patients with primary headaches. Furthermore, we found that doctors issued a neuroimaging request for patients with primary headaches mostly, to exclude the risk of misdiagnosis, reduce uncertainty, avoid medical disputes, meet patients’ medical needs, and complete hospital assessment indicators.
Conclusions
For primary headaches, the probability of clinicians requesting neuroimaging was higher in China than in other countries. There is considerable room for improvement in determining appropriate strategies to reduce the use of low‐value care for doctors and patients.
... Although headache imaging is mainly performed to exclude secondary forms [3], numerous studies have explored the pathological pathways and morphological changes associated with headache, mainly by means of magnetic resonance (MRI) [4][5][6][7][8][9]. Limited evidence of functional brain changes has been reported using [ 18 F]Fluorodeoxyglucose ([ 18 F]FDG) positron emission tomography (PET) [3,4,[10][11][12][13]. ...
... Although headache imaging is mainly performed to exclude secondary forms [3], numerous studies have explored the pathological pathways and morphological changes associated with headache, mainly by means of magnetic resonance (MRI) [4][5][6][7][8][9]. Limited evidence of functional brain changes has been reported using [ 18 F]Fluorodeoxyglucose ([ 18 F]FDG) positron emission tomography (PET) [3,4,[10][11][12][13]. Previous studies have identified regions of relative hypometabolism in MiG patients, including the bilateral insula and cingulate cortex, left premotor and prefrontal cortex, and left visual and left primary somatosensory cortex [10]. ...
Simple Summary
[¹⁸F]Fluorodeoxyglucose ([¹⁸F]FDG) positron emission tomography (PET) provides information about metabolic patterns of different diseases and conditions. This study aimed to prospectively evaluate patients with breast cancer in order to describe specific brain metabolic patterns related to the presence or absence of primary forms of headache, namely tension-type headache (TTH) and migraine (MiG). Moreover, we explored the association between primary headache forms and BC response to neoadjuvant chemotherapy (NAC). We observed a high rate of headache in the 46 BC analyzed patients. TTH patients exhibited areas of hypometabolism in specific brain regions before NAC. Moreover, our results suggest an association between primary headache, especially MiG, and treatment response to NAC. Collectively, our results support the hypothesis of a complex and dynamic interplay among BC, headache, and hormonal status.
Abstract
This study aimed to examine brain metabolic patterns on [¹⁸F]Fluorodeoxyglucose ([¹⁸F]FDG) positron emission tomography (PET) in breast cancer (BC), comparing patients with tension-type headache (TTH), migraine (MiG), and those without headache. Further association with BC response to neoadjuvant chemotherapy (NAC) was explored. In this prospective study, BC patients eligible for NAC performed total-body [¹⁸F]FDG PET/CT with a dedicated brain scan. A voxel-wise analysis (two-sample t-test) and a multiple regression model were used to compare brain metabolic patterns among TTH, MiG, and no-headache patients and to correlate them with clinical covariates. A single-subject analysis compared each patient’s brain uptake before and after NAC with a healthy control group. Primary headache was diagnosed in 39/46 of BC patients (39% TTH and 46% MiG). TTH patients exhibited hypometabolism in specific brain regions before NAC. TTH patients with a pathological complete response (pCR) to NAC showed hypermetabolic brain regions in the anterior medial frontal cortex. The correlation between tumor uptake and brain metabolism varied before and after NAC, suggesting an inverse relationship. Additionally, the single-subject analysis revealed that hypometabolic brain regions were not present after NAC. Primary headache, especially MiG, was associated with a better response to NAC. These findings suggest complex interactions between BC, headache, and hormonal status, warranting further investigation in larger prospective cohorts.
... Consistent with our study, previous studies found that even if no red ag or focal neurological abnormalities existed, doctors in the United States might offer a range of reasons, such as defensive medicine, community standard of care, concerns about professional reputation being affected, fear of litigation and sanctions, avoidance of patient dissatisfaction (such as patients insisting on perfect imaging, especially in pediatrics), and interest in proving that patient imaging is the right choice. [23][24][25][26][27][28][29][30][31] In addition, the impact of social media, patient dissatisfaction, and satisfaction surveys increase the sensitivity of clinicians to patient preferences and may also cause doctors to struggle to resist strong patient demands. 3 Most clinicians believe that improving imaging for patients with primary headaches is not low-value care, as previously mentioned, and imaging tests with negative ndings may reduce patient or family anxiety, providing an anxiolytic effect for multiple parties (including providers). ...
Background
Neuroimaging is overused globally in patients with primary headaches. Evidence of this is lacking in China. We aimed to investigate the prevalence of neuroimaging in patients with primary headaches and the clinician-based rationale for requesting neuroimaging in China.
Methods
This was a cross-sectional survey of hospitals and clinicians in China. We used a convenience sampling method to recruit patients with primary headaches admitted to six hospitals in three provincial capitals in 2022. We identified whether neuroimaging had been requested and the types of neuroimaging conducted. We interviewed clinicians using a combination of personal in-depth and topic selection group interviews to explore why doctors request neuroimaging.
Results
Among 2,263 patients recruited for this study, 1,942 (89.75%) underwent neuroimaging. Patients underwent head computed tomography (CT), 628 (27.75%); magnetic resonance imaging (MRI), 1,157 (51.13%); or both CT and MRI, 246 (10.87%). Fifteen of the 16 interviewed clinicians would not issue a neuroimaging request for patients with primary headaches. Further, we found that doctors issued a neuroimaging request for patients with primary headaches mostly to exclude the risk of misdiagnosis, reduce uncertainty, avoid medical disputes, meet patients’ medical needs, and complete the hospital assessment indicators.
Conclusions
For primary headaches, the probability of clinicians requesting neuroimaging is higher in China than in other countries. There is considerable room for improvement in finding appropriate strategies for doctors and patients to reduce the use of low-value care.
... In addition, the negative predictive value of brain MRI should be taken into account, since demonstrating the absence of structural anomalies will likely decrease the patient's fear of a fatal lesion and the anxiety of a worse vital prognosis, decreasing healthcare costs secondary to excessive demand of health resources [19]. Finally, in this same vein, the health care costs derived from neuroimaging studies should also be considered; in the United States, the average cost of a brain MRI exam is 660 dollars (double that of a CT scan [20]) and makes up 1 billion dollars in annual costs [21]. In European countries the cost is lower, but it still represents a substantial part of the indirect costs derived from headache, which in 2010 was estimated to be 27 million euros in the European Union [22]. ...
Headache disorders (HDs) are among the most common conditions of the central nervous system, with an estimated prevalence of 50% in adult population. The aim of this work is to analyze the prevalence of structural anomalies that may explain HDs in MRI exams performed to rule out secondary headache in real-world practice, as well as risk factors associated with these lesions. We conducted a retrospective observational study based on a consecutive case series of all patients that underwent brain MRI due to headache from 1 January 2019 to 31 May 2019. We included patients from six MRI diagnostic centers accounting for four provinces of Andalusia (southern Spain). Bivariate and multivariate logistical regression models were performed to identify risk factors associated with the outcomes (1) presence of a structural finding potentially explaining headache, (2) presence of intracranial space-occupying lesions (SOLs), and (3) presence of intracranial tumors (ITs). Of the analyzed sample (1041 patients), a structural finding that could explain headache was found in 224 (21.5%) patients. SOLs were found in 50 (6.8%) patients and ITs in 12 (1.5%) patients. The main factors associated with structural abnormalities were female sex (OR, 1.35; 95% CI, 1.02–1.85), accompanying symptoms (OR, 1.34; 95% CI, 1.05–1.89), use of gadolinium-based contrast agents (OR, 1.89; 95% CI, 1.31–2.72) and previously known conditions potentially explaining headache (OR, 2.44; 95% CI, 1.55–3.84). Female sex (p = 0.048) and accompanying symptoms (p = 0.033) were also associated with ITs in bivariate analyses. Our results may be relevant for different medical specialists involved in the diagnosis, management and prevention of headache. Moreover, the risk factors identified in our study might help the development of public health strategies aimed at early diagnosis of brain tumors. Future studies are warranted to corroborate our findings.
... Neuroimaging techniques have shown to represent a valuable diagnostic bridge between neurophysiological studies and clinical findings [18]. At the same time, it is important to consider the low yield of imaging procedures for individuals presenting with headache unaccompanied by other neurological findings [19][20][21][22][23][24]. ...
Headache is one of the most common human afflictions. In most cases, headaches are benign and idiopathic, and resolve spontaneously or with minor therapeutic measures. Imaging is not required for many types of headaches. However, patients presenting with headaches in the setting of “red flags” such as head trauma, cancer, immunocompromised state, pregnancy, patients 50 years or older, related to activity or position, or with a corresponding neurological deficit, may benefit from CT, MRI, or noninvasive vascular imaging to identify a treatable cause. This publication addresses the initial imaging strategies for headaches associated with the following features: severe and sudden onset, optic disc edema, “red flags,” migraine or tension-type, trigeminal autonomic origin, and chronic headaches with and without new or progressive features.
The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.
... Until now, neuroimaging has been considered unnecessary for primary headache patients, especially those with chronic headache and no focal neurological signs. 5,6,37 As such, cost effectiveness should be evaluated according to headache type, symptoms and signs, and the implemented neuroimaging tool. ...
Objective:
Neuroimaging in headache patients identifies clinically significant neurological abnormalities and plays an important role in excluding secondary headache diagnoses. We performed a systematic review and meta-analysis of the existing guidelines and studies surrounding neuroimaging in headache patients.
Methods:
The research question involved determining the prevalence of detecting clinically significant neurological abnormalities using neuroimaging in patients suspected of primary headache. Searches of the PubMed and Embase databases were conducted on English-language studies published from 1991 to 2016, and the reference lists of the retrieved articles were also checked manually. All headache subtypes and patients aged ≥15 years were included in the analysis.
Results:
Ten studies met the selection criteria. The pooled prevalence of detecting clinically significant abnormalities in the neuroimaging of headache patients was 8.86% (95% confidence interval: 5.12-15.33%). Subsequently, diverse subgroup analyses were performed based on the detection method, headache type, study type, study region, age group, and disease type.
Conclusion:
The present findings indicate that limited neuroimaging methods should be carefully considered for headache diagnostic purposes when there are red flag symptoms. Limitations and suggested directions for future studies on neuroimaging in headache patients are described.
... Moreover, neuroimaging might reassure patients and improve their quality of life. 7,15,17 In China, the tense relationships and lower levels of trust between physicians and patients were another important cause. 18,19 Finally, we would like to restate the limitations of the present findings. ...
Background – Headache may be due to either a primary or secondary disorder, and neuroimaging assessments can play an important role when differentiating between these types of headache. Although many studies have reported no significant differences between primary headache patients and the general population in terms of abnormal neuroimaging findings, others have shown that neuroimaging may be employed to rule out secondary causes of headache that could impact morbidity and mortality. This issue remains under debate. Thus, the present study compared the neuroimaging findings of headache patients and healthy controls.
Methods – This study recruited 1070 healthy controls and 1070 primary headache patients from the Chinese People’s Liberation Army General Hospital. The primary headache patients were diagnosed by computerized clinical decision support systems, and re‐diagnosed by a specialist. All participants were assessed with either computed tomography or magnetic resonance imaging (MRI) scans. The neuroimaging findings were classified as significant abnormalities, non‐significant abnormalities, or normal.
Results – All the significant abnormalities were found using MRI scans. Significant abnormalities were identified in 4 primary headache patients (0.58%) and 5 healthy controls (0.73%); the rate of significant abnormalities was not significant different between both groups (P > .05).
Conclusions – The present study found that neuroimaging was unnecessary for the primary headache patients.
... MRI, which is free of ionizing radiation and relatively low in cost, can reduce these unnecessary appointments and indicate appropriate referral and treatment when required. However, MRI scanners require patients to be fully enclosed within the scanner, which can lead to claustrophobia and restricts the availability of scanning for bariatric patients 25 . ...
The aim of this study was to evaluate the reported presence of magnetic resonance imaging (MRI) pathologies (demyelination, space-occupying lesions, or trigeminal neurovascular contact within the transition zone) in patients with orofacial pain. Patient histories, demographic characteristics, and clinical features were compared between those with and without a reported MRI pathology. A retrospective service evaluation of all patients who had undergone MRI scanning to aid the diagnosis of orofacial pain conditions between 2012 and 2016 was conducted. Data were collected and statistical analyses (frequency and descriptive) performed. One hundred and twenty-five patients (34 male and 91 female) with a mean age of 50 years were included. MRI pathologies included space-occupying lesions (2.4%), trigeminal neurovascular contact (22.4%), other pathology including small vessel cerebrovascular disease (20%), pineal cyst (1.6%), sinus pathologies (1.6%), and degenerative changes to the cervical spine (0.8%). This study found that patients with a provisional diagnosis of trigeminal neuralgia or trigeminal autonomic cephalalgia, as well as patients with elicited pain, were more likely to have abnormal findings on MRI scanning.
... Even though significant brain MRI findings in migraine and tension-type headaches are rare, some literature recommend brain MRI to rule out secondary causes of tension-type headaches and chronic migraine [150,151]. One reason is the last criterion in the ICHD-3 diagnosis of primary headaches, "Not better accounted for by another ICHD-3 diagnosis". ...
Headaches are one of the most common complaints among humans as well as the most
frequent reason for patients seeking health-care. Due to the huge geographical area of
coverage for the two Departments of Neurology in Northern Norway, headache patients
have variable accessibility and availability to proper specialist care. Few headache specialists
and poor access to care may lead to misdiagnosis, suboptimal treatment and inconvenience
with follow-up plans for headache patients.
We want to compensate for these unfortunate conditions, and designed a non-inferiority
randomized controlled trial in an attempt to demonstrate whether there are differences in
outcome of neurologic consultations depending on assessment method; telemedicine versus
traditional in-person headache visits. To accomplish this, we investigated endpoints of
different aspects, and compared telemedicine to traditional visits in patient satisfaction,
treatment efficacy, safety and feasibility. Additionally, we assessed headache patients’
acceptability of telemedicine, and evaluated the cost savings.
The results showed that most headache patients accept telemedicine, and are satisfied with
the consultation type. Virtually all endpoints in the trial indicated that specialist headache
visits via telemedicine is non-inferior to traditional in-patient visits. We thus consider
telemedicine as a good alternative for most patients with nonacute headache referred to a
secondary neurology department. This trial will serve as a base for further research on
ehealth services, and for the establishment of telemedicine consultations for headache
patients in clinical practice.
Background:
Lymphomas of parapharyngeal space often have complex manifestations, posing a diagnostic dilemma for clinicians.
Case description:
A 64-year-old man sought treatment for a 4-month history of unresolving right-sided headache and jaw pain associated with syncope, all of which started with a toothache. Since the onset of pain, the patient had undergone multiple diagnostic tests with various specialists, with no pain relief. A detailed clinical and radiologic examination by an orofacial pain specialist revealed diffuse large B-cell lymphoma in the parapharynx.
Practical implications:
A thorough knowledge of the head and neck anatomy helps in identifying the pathophysiology of complex orofacial pain manifestations, which assists in early diagnosis and treatment.
