1) A study examined neuroimaging results from 530 new headache patients referred to an outpatient consultation service over 5 years. 2) Significant abnormalities were found in 11 patients (2.1%), including 6 brain tumors. 3) Migraine and tension-type headache patients had similar low rates of significant abnormalities (1.2% and 0.9%) as seen in normal individuals (0.7-2%). 4) The study supports selective neuroimaging in headache patients based on worrying features, as prevalence of significant findings is low.

1. IMAGING RESULTS IN A CONSECUTIVE SERIES OF 530 NEW PATIENTS IN THE BIRMINGHAM HEADACHE SERVICE NEUROLOGY JOURNAL CLUB KSHITIJA KARI, MD PGY-III

2. INTRODUCTION Which patients with headache disorders should undergo neuroimaging? UK & USA guidelines (National Institute for Health, American Academy of Neurology) suggest selective policy for imaging as prevalence of significant findings is low High referral rate leads to increased discovery of incidental findings on imaging However, clinicians continue to refer such patients for imaging for reassurance and patient satisfaction

4. 1 diagnostic headache nurse specialist

7. no diagnostic pattern, wakes from sleep

8. Precipitated by coughing, straining, etc.

10. focal neurological signs

11. epilepsy

12. cognitive disturbance

15. 69% female, mean age 42yrs

16. 56% white, 34% Asian and 11% Afro-Caribbean

17. Total of 530 of the 3655 patients were referred for imaging

20. RESULTS

22. RESULTS Total 11 significant abnormalities (2.1%) 6 brain tumors: 4 clinically suspected 2 not suspected 167 Migraine patients imaged: 2 significant abnormalities (1.2%) 212 tension type headache: 2 significant abnormalities (0.9%) 55 Intracranial abnormalities: 3 significant abnormalities (5.5%)

23. DISCUSSION 530 Headache patients with worrying features only 2.1% significant abnormalities. Study showed more significant abnormalities with MRI compared with CT. Selection of MRI over CT- reduce radiation exposure dose, better imaging quality, more sensitive However, do not know if patients who were not imaged had any significant intracranial pathology

24. OTHER STUDIES Meta-analysis of 11 studies of imagingmigraine patients with normal neuro exam & no red flags - 0.18% [1] 2 studies in tension-type headache - 83 pts. [1] Spanish study: 1876 patients p/w non acute headache 1.2% (0.4% migraine & 0.8% tension) significant abnormalities. [2] Meta-analysis of 16 studies of MRI in 19,559 normal people found 0.7% neoplastic & 2.0% of non-neoplastic incidental findings. [3]

25. DISCUSSION So, prevalence of significant findings in migraine and tension headache is similar to that in normal individuals. MRI showed more frequent insignificant and incidental findings in this study (occult CV disease). Already worried patients may deteriorate if told of such coincidental findings.

26. DISCUSSION Number of patients referred for imaging fell from 35% to 13.5% the following year after results were disclosed. Feedback had an effect on consultants, as proportion of patients imaged lowered than at the outset. Excluding cases with known pre-existing pathology and with unrelated pathology (meningioma, pineal tumor) reduces incidence to 1.1% (Spanish-1.2%).

27. Discussion Question Can you think of any problems generalizing these results to the population we serve?

28. CONCLUSION The study supports current UK and American guidelines in advising the selective use of neuroimaging in small proportion of headache pts with sinister features either in history, exam or other investigations. The proportion of headache patients imaged by consultants can be reduced by giving feed back on data on their rate of imaging and its sensitivity.

29. Thank You Dr. B. Desai Dr. A. Acharya Dr. N. Nelson Dr. A. Haefner Dr. M. Do

30. References References: [1] The utility of Neuroimaging in the evaluation of headache in patients with normal neurological examinations. American Academy of Neurology 2008 [2] Neurimaging in the evaluation of patients with non-acute headache. Sempere AP, et al, Cephalalgia 2005 [3] Incidential findings on brain magnetic resonance imaging:systematic review and meta-analysis. Morris Z, et al, BMJ 2009