Members of the American Headache Society (AHS) have released an evidence-based guideline that provides recommendations on neuroimaging for migraine. The guideline was published in Headache.
In the guideline, the AHS committee report findings from a systematic review, which included studies of adults who sought outpatient treatment for migraine and who underwent neuroimaging, either magnetic resonance imaging (MRI) or computed tomography (CT) scans. A total of 23 articles, most of which were retrospective cohort or cross-sectional studies, met inclusion criteria. The utility of CT was assessed in 10 studies, whereas MRI was assessed in 9 studies, and both modalities were examined in 4 studies.
Both scanning modalities frequently detected chronic ischemia or atrophy, whereas MRI detected non-specific white matter lesions. There was no difference between the general population and patients with headaches consistent with migraine but without atypical features in terms of clinically significant neuroimaging abnormalities. Based on this finding, the AHS guideline states that neuroimaging in these patients who have a normal neurologic examination is not necessary.
In cases of presumed migraine, the AHS guideline committee suggests that grade A neuroimaging may be considered in patients with unusual, prolonged, or persistent aura or patients with increasing frequency, severity, or change in clinical features, first or worst migraine, migraine with confusion, migraine with motor manifestations (hemiplegic migraine), migraine with brainstem aura, aura without headache, side-locked headache, late-life migraine accompaniments, and posttraumatic headache. These recommendations were based on consensus, however, and were not made based on literature review.
The guideline committee wrote that their recommendations do not require “any particular course of medical care and is not intended to substitute for the independent professional judgment of the treating provider, as the information does not account for individual variation among patients.”
Evans RW, Burch RC, Frishberg BM, et al. Neuroimaging for migraine: The American Headache Society systematic review and evidence-based guideline [published online December 31, 2019]. Headache. doi:10.1111/head.13720