The tentorial nerve is a branch from V1. Do you think, diagnostic neuroimaging

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1 Radiology in headache: your patient wants a scando you want it too? The tentorial nerve is a branch from V1 Arne May, Dept. of Systems Neuroscience, University of Hamburg (UKE) (Feindel et al., Neurology 1960; 10:555) Do you think, Epidemiology of headaches that all patients with a headache should be scanned? at least once in their lifetime? only patients without a migraine? all patients including migraine? of people: developed a headache in the last year had strong or even unbearable headaches went to their family doctor for their headaches were 272 referred to a neurologist had 10 a brain tumor but only 0.5 a brain tumor without neurological symptoms Hopkins (1988) diagnostic neuroimaging X-Ray sinusitis CCT SAB/ICB acute bone destruction The 5 recommendations approved by the AHS Board of Directors are: MRI SAB/ICB old brain tissue (tumor etc) Angiography aneurysm vasculitis 1

2 2nd IHS classification headache types, 14 main groups Should every patient with headaches get a work up including neuroimaging migraine and normal neurological examination (n=897) 0.4% abnormal primary headaches secondary headaches neuralgias unspecified % 7,8% 0,2% non-migraine patients and normal neurological examination (n=1825) 2.4% abnormal Wang HZ et. al; Acad Radiol (2001); 8 (5): Katzman et al., JAMA 1999; 281: Alter et al., Neurology 1994; 44: Quality Standards Subcommittee of the American Academy of Neurology MRI in chronic headache patients Of 402 patients with headache: 15 patients (3.7%) with pathology Evidence-based guidelines in the primary care setting: Neuroimaging in patients with non-acute headache US Headache Consortium 2002 EFNS-Task Force 2004 Review of 28 studies, all Level IV = Recommendations are consensus without evidence 0.6% in patients with migraine 1,4% in patients with tension-type headache 3,8% in patients with other headaches 14,1% in patients with atypical headache migraine: TTH: CCT vs. MRI: Neuroimaging when: no neuroimaging necessary no recommendation possible no recommendation possible headache atypical or anormal neurological examination Wang HZ et. al; Acad Radiol (2001); 8 (5): URL: Eur J Neurol (2004) 11 (4): Hazards of neuroimaging Risks of imaging Chance finding without pathological significance Tension type headache Tension type headache MRI shows asymptomatic aneurysm MRI shows hydrocephalus feeling of uncertainty of the doctor & the patient Coiling of aneurysm Ventrikulo-peritoneal shunt Hemiparesis as a consequence = medical opinion Subdural haematoma as a consequence = medical opinion 2

3 Hazards of neuroimaging Chance finding without pathological significance feeling of uncertainty of the doctor & the patient The most important ancillary diagnostics: Headache as an Emergency If clinic is IHS conform and neurological examination normal: The likelihood of irrelevant incidental findings is higher than the likelihood of a therapeutically relevant diagnostic finding. reflex hammer Every first-time and atypical headache and every dramatic change of headache characteristics is suspicious to be a secondary headache (and needs to be seen by a neurologist)! Emergency or not? Neuroimaging: who. Mr. K., 42 years old, reported a sudden headache 2 weeks ago when lifting a cupboard. The headache was unspecific and lasted for 3 hours. Mrs. B., 34 years old, suffered a very severe occipital headache when lying on the bed and reading a book, when the doorbell went off. First time Atypical Sudden onset Severe 3

4 Imaging: When? Neuroimaging: 4 Specialists... no clear-cut primary headache (IHS) pathological neurological examination primary headache, but - change in therapeutic efficacy - change in phenotype progressive clinic (Aura) first time headache? patient request? Thunderclap headache Position-dependent headache Headaches made worse by exercise Trigemino-autonomic headaches ACR Appropriateness Criteria Headache Annette C. Douglas, Franz J. Wippold II, Daniel F. Broderick, Ashley H. Aiken, Sepideh Amin- Hanjani, Douglas C. Brown, Amanda S. Corey, Isabelle M. Germano, James A. Hadley, Bharathi D. Jagadeesan, Jennifer S. Jurgens, Tabassum A. Kennedy, Laszlo L. Mechtler, Nandini D. Patel, Gregory J. Zipfel, Journal of the American College of Radiology, Volume 11, (7), Pages Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma new, worse, or abrupt onset Thunderclap radiating to the neck due to trigeminal autonomic cephalgia persistent and positional and temporal in older individuals Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Detsky et al. JAMA 2006; 296: Headaches associated with cough, exertion, or sexual activity usually require neuroimaging Primary versus secondary Headaches I told you it was organic 4

5 functional imaging Doppler/Duplex/NIRS SPECT PET F-MRI MEG Spectroscopy Structural imaging Headache Signatures Headache history Relevant Points: - first-time or familiar headache - Onset: acute or slow, when - Localisation: uni-/bilateral, punctum maximum, Spread - Headache Character - Temporal Dynamics: attack-like vs. chronic, frequency, circadian or circanual rhythm - Magnitude (0-10 on the VRS) - Aura - vegetative Symptoms (nausea, vomiting, photo-, phonoand osmophobia) - autonome Symptoms (ptosis, lacrimation, conjunct. Injection, Rhinorrhoea, nasal congestion...) - Getting worse with exercise, bending down, pressing, position-dependent - Family history of headaches The dangerous headache A short medical history demands speed, a long history requires time! 5

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