×

Web site maintenance has been scheduled on 20/01/2022 from 9pm to 10pm AEDT, minor disruptions may occur.


Clinical guidance for MRI referral

MRI of the head

Unexplained chronic headache

MBS item description

Referral by a medical practitioner (excluding a specialist or consultant physician) for a scan of head for a patient 16 years or older for unexplained chronic headache with suspected intracranial pathology (R) (K) (Contrast) (Anaes.)

Key information

  • In most headache syndromes there is a lack of evidence to suggest imaging improves health outcomes.
  • Most common headache types can be diagnosed on history and examination.
  • Investigations including neuroimaging are only indicated when history or examination suggests headache is secondary to serious intracranial pathology.
  • Abnormalities detected on neuroimaging may not be clinically significant but may lead to further unnecessary investigations or interventions.
  • Neuroimaging for reassurance is not recommended.
  • ​This guidance does not cover acute headache.

Explanation
B - High-quality systematic reviews of case–control or cohort studies, directly applicable to the target population, and demonstrating overall consistency of results
or
Extrapolated evidence from high quality meta-analyses, systematic reviews of randomised controlled trials (RCTs), or RCTs with a very low risk of bias or well conducted meta-analyses, systematic reviews, or RCTs with a low risk of bias.

Recommendation
Neuroimaging should be considered in patients with headache and an unexplained abnormal finding on the neurological examination

Explanation
The US Headache Consortium achieved consensus on the recommendation in the absence of relevant RCTs

Recommendation
Neuroimaging could be considered for headache worsened by Valsalva manoeuvre, headache causing awakening from sleep, new headache in an older patient, or progressively worsening headache†

Grade: None given

Recommendation
Neuroimaging is not indicated for people diagnosed with tension-type headache, migraine, cluster headache or medication overuse headache solely for reassurance

Headache is one of the most common neurological problems presented to GPs. People with headache and their healthcare professionals can be worried about possible serious underlying disease.20,21

Headaches disorders are classified as either primary or secondary and these are further divided into specific headache type.20,22

Primary headache disorders, including migraine, tension-type and cluster headaches, account for the majority of headaches.23The aetiology of primary headaches is poorly understood and they are differentiated by their clinical patterns.22

Table 2.4 Clinical patterns of primary headaches

Table 2.4

Clinical patterns of primary headaches

Investigations, including neuroimaging, do not contribute to the diagnosis of migraine or tension-type headache. Some guidelines, but not all, recommend brain MRI in patients with cluster headache due to the small possibility of a serious underlying structural lesion.24

Secondary headaches, are attributed to underlying disorders.20 The most common secondary headache is due to medication overuse, which occurs most commonly in those taking medication for a primary headache disorder.20 Headache may also be referred from the muscles, joints and ligaments of the upper three cervical segments due to the convergence of nociceptive afferent nerves from these segments with those of the trigeminal nerve.25

Serious causes of secondary headaches include tumour, infection, bleeding and arteritis.24,26 These warrant further investigation, which may include imaging. Note that MRI will not detect all serious causes of secondary headache, such as giant cell arteritis.6

Table 2.5 Intracranial tumours

Table 2.5

Intracranial tumours


Table 2.6 Giant cell arteritis

Table 2.6

Giant cell arteritis


For detailed explanations of headache classifications go to the International Headache Society Classification page.

What findings increase the suspicion of intracranial pathology?

People with headache alone are unlikely to have serious underlying disease.22 Serious intracranial pathology as the cause of headache is rare (e.g. space-occupying lesion <1%, idiopathic intracranial hypertension <1%, chronic meningitis <1% and giant cell arteritis <1%).6

The SNOOP mnemonic is a useful reminder of clinical features that may indicate a secondary headache with serious underlying cause.27,28

Table 2.7 The SNOOP-4 mnemonic

Table 2.7

The SNOOP-4 mnemonic

History

Patients with increased intracranial pressure may report symptoms such as:

  • a frontal headache that is worse after lying down, most notable in the morning and wakes the patient from sleep but improves during the day
  • vomiting, particularly early morning and not associated with nausea
  • blurred vision
  • personality or behavioural changes.

In imaging studies, the following symptoms have been shown to increase the odds of finding a significant abnormality on neuroimaging: rapidly increasing headache frequency, history of dizziness or lack of coordination, history of subjective numbness or tingling, or history of headache causing awakening from sleep.21

Physical examination

Examination of patients presenting with headache should include:20,22

  • blood pressure
  • examination of temporal arteries
  • neck examination, including palpation for posterior cervical tenderness
  • fundoscopy (where the doctors is experienced in its use)
  • cranial nerve assessment, especially pupils, visual fields, eye movements, facial power and sensation, and bulbar function (soft palate, tongue movement)
  • assessment of tone, power, reflexes and coordination in all four limbs
  • plantar responses
  • assessment of gait, including heel–toe walking.

There should be more detailed assessment if prompted by the history. The examination should be tailored to include any focal neurological symptoms.20

An abnormal neurological examination significantly increases the likelihood of finding an abnormality on neuroimaging.21

The choice between CT and MRI may depend on the situation. In emergency situations, CT is generally recommended.

SIGN suggests that MRI is the imaging modality of choice because of its greater sensitivity.20

MRI does appear to be more sensitive in finding white matter lesions and developmental venous anomalies than CT.20,21However, this greater sensitivity appears to be of little clinical importance in the evaluation of patients with chronic headache, as MRI may just be better at identifying incidental abnormalities.21

The relative rarity of secondary headaches – compared with the large number of patients with primary headache – and the potential to reveal incidental abnormalities raise concerns about the balance between risk and benefits of neuroimaging studies (either CT or MRI) to exclude underlying causes of headache.21

The major benefit of neuroimaging is the detection of significant and treatable lesions that impact the quality of life.21 The risk is finding incidental abnormalities that may cause anxiety and potential harm with further investigations and treatments. MRI, with its greater sensitivity, may be better at finding abnormalities – both significant and insignificant.

The ‘benefit’ of alleviating patient anxiety about having an underlying pathologic condition by obtaining a negative or normal scan does not appear to be a significant or sustained benefit.20,22 A randomised controlled trial of 150 patients with chronic daily headache in a specialist clinic found that patients who received MRI had a decrease in anxiety levels at 3 months, but that the reduction in anxiety was not maintained at 1 year.20

Other risks include false reassurance from an inadequate study and the risk of over-sedation in claustrophobic patients having MRI scans.21

  1. Chou R, Qaseem A, Owens DK, Shekelle P. Clinical Guidelines Committee of the American College of Physicians. Diagnostic imaging for low back pain: advice for high-value health care from the American College of Physicians. Ann Intern Med 2011;154(3):181–89.
  2. Brito JP, Morris JC, Montori VM. Thyroid cancer: zealous imaging has increased detection and treatment of low risk tumours. BMJ 2013;347:f4706.
  3. Royal Australian and New Zealand College of Radiologists (RANZCR). Radiology written report guideline, (short) version 5 (final). Sydney: RANZCR, 2011.
  4. Lehnert BE, Bree RL. Analysis of appropriateness of outpatient CT and MRI referred from primary care clinics at an academic medical center: how critical is the need for improved decision support? J Am Coll Radiol 2010;7(3):192– 97.
  5. Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ 2012;344:e3502.
  6. Royal Australian and New Zealand College of Radiologists (RANZCR). Guidance for GP referrals for MRI studies. Sydney: RANZCR, 2013.
  7. Krumholz A, Wiebe S, Gronseth G, et al. Practice parameter: Evaluating an apparent unprovoked first seizure in adults (an evidence-based review): report of the quality standards subcommittee of the American Academy of Neurology and the American Epilepsy Society. Neurology 2007;69(21):1996–2007.
  8. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of epilepsy in adults: a national clinical guideline. Edinburgh: SIGN, 2003.
  9. National Institute for Health and Clinical Excellence (NICE). The epilepsies: diagnosis and management of the epilepsies in adults in primary and secondary care. London: NICE, 2012.
  10. King MA, Newton MR, Jackson GD, et al. Epileptology of the first-seizure presentation: a clinical, electroencephalographic, and magnetic resonance imaging study of 300 consecutive patients. Lancet 1998;352(9133):1007–11.
  11. Wilden JA, Cohen-Gadol AA. Evaluation of first nonfebrile seizures. Am Fam Physician 2012;86(4):334.
  12. Berg AT. Risk of recurrence after a first unprovoked seizure. Epilepsia 2008;49:13–18.
  13. Pohlmann-Eden B, Beghi E, Camfield C, Camfield P. The first seizure and its management in adults and children. BMJ 2006;332(7537):339–42.
  14. Adams SM, Knowles PD. Evaluation of a first seizure. Am Fam Physician 2007;75:1342–47.
  15. Hamilton W, Kernick D. Clinical features of primary brain tumours: a case–control study using electronic primary care records. Br J Gen Pract 2007;57(542):695–9.
  16. Harden CL, Huff JS, Schwartz TH, et al. Reassessment: Neuroimaging in the emergency patient presenting with seizure (an evidence-based review): report of the therapeutics and technology assessment subcommittee of the American Academy of Neurology. Neurology 2007;69(18):1772–80.
  17. Smirniotopoulos JG, Wippold FJ, Cornelius RS, Angtuaco EJ, Broderick DF, Brown DC. Expert panel on neurologic imaging. ACR appropriateness criteria – seizures and epilepsy [Online publication]. Reston, VA: American College of Radiology (ACR), 2011.
  18. Morris Z, Whiteley WN, Longstreth WT, et al. Incidental findings on brain magnetic resonance imaging: systematic review and meta-analysis. BMJ 2009;339:b3016.
  19. Vattipally VR, Bronen RA. MR imaging of epilepsy: strategies for successful interpretation. Neuroimaging Clin N Am 2004;14(3):349–72. Scottish Intercollegiate Guidelines Network (SIGN). Diagnosis and management of headache in adults. A national clinical guide. Edinburgh: NHS Scotland, 2008.
  20. Frishberg BM, Rosenberg JH, Matchar DB, et al. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache. The American Academy of Neurology, 2000.
  21. National Clinical Guideline Centre. Headaches: diagnosis and management of headaches in young people and adults. Methods, evidence and recommendations. London: NICE, 2012.
  22. Nunes VD, Sawyer L, Neilson J, Sarri G, Cross JH. Diagnosis and management of the epilepsies in adults and children: Summary of updated NICE guidance. BMJ 2012;344:e281.
  23. Steiner TJ, MacGregor EA, Davies PTG. Guidelines for all healthcare professionals in the diagnosis and management of migraine, tension-type, cluster and medication-overuse headache. British Association for the Study of Headache 2007;2007:1–52.
  24. Bogduk N. The anatomical basis for cervicogenic headache. Journal of Manipulative and Physiological Therapeutics 1992;15(1):67–70.
  25. Carville S, Padhi S, Reason T, Underwood M. Diagnosis and management of headaches in young people and adults: summary of NICE guidance. BMJ 2012;345:e5765 doi:10.1136/bmj.e5765.
  26. Davies MB. How do I diagnose headache? J R Coll Physicians Edinb 2006;36(4):336.
  27. Zagami AS, Goddard SL. Recurrent headaches with visual disturbance. Med J Aust 2012;196(3):178–83.
  28. North American Spine Society (NASS). Diagnosis and treatment of cervical radiculopathy from degenerative disorders. Burr Ridge, Ill: NASS, 2010.
  29. National Institute for Health and Clinical Excellence (NICE). Clinical knowledge summaries: neck pain – cervical radiculopathy. Revised January 2009
  30. Nordin M, Carragee EJ, Hogg-Johnson S, et al. Assessment of neck pain and its associated disorders. Eur Spine J 2008;17(1):101–22.
  31. Kuijper B, Beelen A, van der Kallen BF, et al. Interobserver agreement on MRI evaluation of patients with cervical radiculopathy. Clin Radiol 2011;66(1):25–29.
  32. Guzman J, Haldeman S, Carroll LJ, et al. Clinical practice implications of the bone and joint decade 2000-2010 task force on neck pain and its associated disorders: from concepts and findings to recommendations. J Manipulative Physiol Ther 2009;32(2 Suppl):S227–S43.
  33. Reneman L, de Win MM, Booij J, et al. Incidental head and neck findings on MRI in young healthy volunteers: prevalence and clinical implications. Am J Neuroradiol 2012;33(10):1971–74.
  34. Boden SD, Davis DO, Dina TS, Patronas NJ, Wiesel SW. Abnormal magnetic-resonance scans of the lumbar spine in asymptomatic subjects. A prospective investigation. J Bone Joint Surg Am 1990;72(3):403–8.
  35. Medical PA Criteria Proposal. MRI of cervical spine. ACS Heritage, 2005.
  36. Como JJ, Diaz JJ, Dunham CM, et al. Practice management guidelines for identification of cervical spine injuries following trauma: update from the Eastern Association for the Surgery of Trauma Practice Management Guidelines Committee. J Trauma 2009;67(3):651–59.
  37. Bussières AE, Taylor JA, Peterson C. Diagnostic imaging practice guidelines for musculoskeletal complaints in adults – an evidence-based approach. Part 3: Spinal disorders. J Manipulative Physiol Ther 2008;31(1):33–88.
  38. Daffner RH, Weissman BN, Angtuaco EJ, et al. ACR appropriateness criteria® – suspected spine trauma [Online publication]. Reston, VA: American College of Radiology, 2012.
  39. Blackmore CC. Evidence-based imaging evaluation of the cervical spine in trauma. Neuroimaging Clinics of North America 2003;13(2):283–91.
  40. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: neck pain – whiplash injury
  41. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: neck pain – non-specific
  42. Greenbaum J, Walters N, Levy PD. An evidence-based approach to radiographic assessment of cervical spine injuries in the emergency department. J Emerg Med 2009;36(1):64–71.
  43. Blackham J, Benger J. Clearing the cervical spine in the unconscious trauma patient. Trauma 2011;13(1):65–79.
  44. Kongsted A, Sorensen JS, Andersen H, Keseler B, Jensen TS, Bendix T. Are early MRI findings correlated with long-lasting symptoms following whiplash injury? A prospective trial with 1-year follow-up. Eur Spine J 2008;17(8):996–1005.
  45. Horn EM, Lekovic GP, Feiz-Erfan I, Sonntag VK, Theodore N. Cervical magnetic resonance imaging abnormalities not predictive of cervical spine instability in traumatically injured patients: invited submission from the joint section meeting on disorders of the spine and peripheral nerves. J Neurosurg Spine 2004;1(1):39–42.
  46. Muchow RD, Resnick DK, Abdel MP, Munoz A, Anderson PA. Magnetic resonance imaging (MRI) in the clearance of the cervical spine in blunt trauma: a meta-analysis. J Trauma Acute Care Surg 2008;64(1):179–89.
  47. Schuster R, Waxman K, Sanchez B, et al. Magnetic resonance imaging is not needed to clear cervical spines in blunt trauma patients with normal computed tomographic results and no motor deficits. Arch Surg 2005;140(8):762.
  48. New Zealand Guidelines Group. MRI guidelines for the diagnosis of soft tissue knee injuries: internal derangements updated by ACC. Auckland: Accident Compensation Corporation; 2010.
  49. Ryzewicz M, Peterson B, Siparsky PN, Bartz RL. The diagnosis of meniscus tears: the role of MRI and clinical examination. Clin Orthop Relat Res 2007;455:123–33.
  50. Tuite MJ, Daffner RH, Weissman BN, et al. ACR appropriateness criteria® – acute trauma to the knee. J Am Coll Radiol 2012;9(2):96–103.
  51. National Institute for Health and Care Excellence (NICE). Clinical knowledge summaries: knee pain – assessment
  52. Grover M. Evaluating acutely injured patients for internal derangement of the knee. Am Fam Physician 2012;85(3):247–52.
  53. Benjaminse A, Gokeler A, van der Schans CP. Clinical diagnosis of an anterior cruciate ligament rupture: a metaanalysis. J Orthop Sports Phys Ther 2006;36(5):267–88.
  54. Karachalios T, Hantes M, Zibis AH, Zachos V, Karantanas AH, Malizos KN. Diagnostic accuracy of a new clinical test (the Thessaly test) for early detection of meniscal tears. J Bone Joint Surg 2005;87(5):955–62.
  55. Mohan BR, Gosal HS. Reliability of clinical diagnosis in meniscal tears. Int Orthop 2007;31(1):57–60.
  56. Yao K, Haque T. The Ottawa knee rules – a useful clinical decision tool. Aust Fam Physician 2012;41(4):223–24.
  57. Crawford R, Walley G, Bridgman S, Maffulli N. Magnetic resonance imaging versus arthroscopy in the diagnosis of knee pathology, concentrating on meniscal lesions and ACL tears: a systematic review. Br Med Bull 2007;84:5–23.
  58. Boks SS, Vroegindeweij D, Koes BW, Hunink MG, Bierma-Zeinstra SM. Follow-up of posttraumatic ligamentous and meniscal knee lesions detected at MR imaging: systematic review. Radiology 2006;238(3):863–71.
  59. Frobell RB, Roos HP, Roos EM, Roemer FW, Ranstam J, Lohmander LS. Republished research: Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. Br J Sports Med 2013;47(6):373.
  60. Guermazi A, Niu J, Hayashi D, et al. Prevalence of abnormalities in knees detected by MRI in adults without knee osteoarthritis: population based observational study (Framingham Osteoarthritis Study). BMJ 2012;345:e5339.
  61. Ben-Galim P, Steinberg EL, Amir H, Ash N, Dekel S, Arbel R. Accuracy of magnetic resonance imaging of the knee and unjustified surgery. Clin Orthop Relat Res 2006;447:100–4.
  62. Englund M, Felson DT, Guermazi A, et al. Risk factors for medial meniscal pathology on knee MRI in older US adults: a multicentre prospective cohort study. Ann Rheum Dis 2011;70:1733–39.
  63. Behairy NH, Dorgham MA, Khaled SA. Accuracy of routine magnetic resonance imaging in meniscal and ligamentous injuries of the knee: comparison with arthroscopy. Int Orthop 2009;33(4):961–67.
  64. Oldrini G, Teixeira PG, Chanson A, et al. MRI appearance of the distal insertion of the anterior cruciate ligament of the knee: an additional criterion for ligament ruptures. Skeletal Radiol 2012;41(9):1111–20.
  65. Grant R. Overview: brain tumour diagnosis and management/Royal College of Physicians guidelines. J Neurol Neurosurg Psychiatry 2004;75(Suppl 2):ii18–23.
  66. Headache Classification Committee of the International Headache Society. The international classification of headache disorders, 3rd edition (beta version). Cephalalgia 2013;33(9):629–808.
This event attracts CPD points and can be self recorded

Did you know you can now log your CPD with a click of a button?

Create Quick log

Advertising