Updated Guidelines for Neuroimaging in Migraine

Researchers update evidence-based recommendations about when to obtain neuroimaging in patients with migraine. 

In December 2019, Headache® published a review and set of evidence-based guidelines to examine the role of neuroimaging in migraine. We sat down with the guidelines’ lead author, Randolph W. Evans, MD, FAHS, to learn about the guidelines and their implications. 

Updating evidence

The paper provided a much-needed update on the role of neuroimaging in migraine. “When to obtain neuroimaging for the evaluation of migraine is a critical issue which affects every physician who treats migraine,” Dr. Evans says. Neuroimaging is ordered during 12% of outpatient headache visits resulting in about $1 billion of annual costs in the United States.

In 2013, Dr. Evans was part of the task force that authored a Choosing Wisely® paper on tests and procedures that patients and providers should question. “In “Choosing Wisely” we just said that people who meet migraine criteria don’t need to have neuroimaging done at all,” Dr. Evans explains. 

The new guidelines are backed by updated evidence. The paper’s authors found 23 studies that met their inclusion criteria, and studied the literature. They concluded that people who meet ICHD-3 criteria for migraine, including a non-focal neurological exam, are no more likely to have significant neuroimaging findings than the general healthy population. 

New conclusions

The guidelines include two major updates. One, Dr. Evans says, is that it is not necessary to do neuroimaging in patients with headaches consistent with migraine who have a normal neurologic examination. 

Secondly, neuroimaging may be considered for presumed migraine for the following reasons: unusual, prolonged, or persistent aura; increasing frequency, severity, or change in migraine clinical features, first or worst migraine, migraine with brainstem aura, confusional migraine, hemiplegic migraine, late-life migrainous accompaniments, migraine aura without headache, side-locked migraine, and post-traumatic migraine (although this is mostly consensus-based, with little or no literature support).

Consequences of Neuroimaging 

Dr. Evans thinks there is the potential for future research to examine the negative or positive consequences from having a scan done, focusing less on scan findings but instead on issues like healthcare costs and anxiety. ”Even when the yield is low, neuroimaging is often conducted in people with migraine because of the expectations, concerns, and anxiety of patients and family,” he says. 

However, studies suggest that this anxiety can be reduced within the first year of treatment for many patients. In cases where neuroimaging significantly reduces costs for patients with high levels of psychiatric comorbidity, the guidelines recommended establishing strong relationships with patients and educating them about the low yield of neuroimaging. 

Headache®: The Journal of Head and Face Pain is the official journal of the American Headache Society. AHS frequently reviews published research and provides commentary on the work being done to help advance the understanding of headache and face pain. For more analysis on studies published in Headache®, visit the AHS News page.