Headache (Adult, Recent Onset)

Population Covered By The Guidance

This pathway provides guidance on the imaging of adult patients with recent onset headache. Criteria have been developed to risk stratify patients, prior to imaging.

Lead Researcher: Arjun Shivananda

Experts & Contributors: Ferry Dharsono, Ravinder Dhillon

Date reviewed: October 2017

Date Published: February 2018

Image 1 (Computed Tomography): Post-contrast CT showing an irregular lesion in the region of the left caudate nucleus with enhancement. The features are suspicious of a glioblastoma multiforme (Grade IV astrocytoma).

Gliobastoma Multiforme

Image 2a: Post-mortem specimen showing a high grade glioma arising within the brainstem with central necrosis and haemorrhage.

Gliobastoma Multiforme

Image 2b: Post-mortem specimen showing a Glioblastoma (note the presence of necrosis and haemorrhage).

Gliobastoma Multiforme

Image 2c (H&E, x20) : Histological section showing a hypercellular population of atypical fibrillary cells palisading around a central area of necrosis (asterisk) with microvascular proliferation (blue arrows). Scattered mitotic figures are also present. The features amount to a glioblastoma multiforme (Grade IV astrocytoma).

Gliobastoma Multiforme

Image 2d (H&E, x20): Histological section showing pleomorphic cells and nuclear atypia, features consistent with a glioblastoma.

Gliobastoma Multiforme

Superior Sagittal Sinus Thrombosis

Fibrillary Astrocytoma

Astrocytoma

Craniopharyngioma

Dysembryoplastic Neuroepithelial Tumour

Angiomatous Meningioma

Image 9: Histological section showing features consistent with metastatic brain disease with breast as primary source of malignancy.

Metastatic Breast Carcinoma

Red flags’ warrant further imaging
- New headache in the older population
- New onset headache in a patient with a history of cancer or immunodeficiency syndrome
- Headache with mental state changes
- Headache with fever/neck stiffness/meningeal signs
- Headache with focal neurological deficit if not previously recognised in the context of a migrainous aura
- Headache causing wakening from sleep
- Headache in a patient with recent ingestion of amphetamine/cocaine
- Headache in pregnancy/post-partum
- Headache worsened by Valsalva and progressively worsening headache
CT head is the initial imaging modality of choice
Further imaging, MRI ± MRA (Magnetic Resonance Angiography) or MRV (Magnetic Resonance Venography) is dependant on the clinical context

Date of literature search: October 2017

References are graded from Level I to V according to the Oxford Centre for Evidence-Based Medicine, Levels of Evidence. Download the document

Becker WJ, Findlay T, Moga C, Scott NA, Harstall C, Taenzer P. Guideline for primary care management of headache in adults. Canadian Family Physician. 2015;61(8):670-9. (Guidelines). View the reference
US Headache Consortium. Evidence-based guidelines in the primary care setting: neuroimaging in patients with nonacute headache: American Family Physician; 2000. (Guidelines). View the reference
Silberstein SD. Evaluation and emergency treatment of headache. Headache. 1992;32(8):396-407. (Review article). View the reference
Duarte J, Sempere AP, Delgado JA, Naranjo G, Sevillano MD, Claveria LE. Headache of recent onset in adults: a prospective population-based study. Acta Neurol Scand. 1996;94(1):67-70. (Level III evidence). View the reference
Holle D, Obermann M. The role of neuroimaging in the diagnosis of headache disorders. Ther Adv Neurol Disord. 2013;6(6):369-74. (Review article). View the reference
Mitchell CS, Osborn RE, Grosskreutz SR. Computed tomography in the headache patient: is routine evaluation really necessary? Headache. 1993;33(2):82-6. (Level II evidence). View the reference
Dumas MD, Pexman JH, Kreeft JH. Computed tomography evaluation of patients with chronic headache. CMAJ: Canadian Medical Association Journal. 1994;151(10):1447-52. (Level III evidence). View the reference
De Campo J, Villanueva EV. Diagnostic Imaging Clinical Effectiveness fact sheet: Suspected meningitis – role of lumbar puncture and computed tomography. Australasian Radiology. 2005;49(3):252-3. (Review article). View the reference
Hasbun R, Abrahams J, Jekel J, Quagliarello VJ. Computed tomography of the head before lumbar puncture in adults with suspected meningitis N Engl J Med. 2001;345(24):1727-33. (Level III evidence). View the reference
Kuhn MJ, Shekar PC. A comparative study of magnetic resonance imaging and computed tomography in the evaluation of migraine. Comput Med Imaging Graph. 1990;14(2):149-52. (Level II evidence). View the reference
Bnaya A, Nesher G, Sonenblick M, Breuer GS. Giant cell arteritis--old questions, current answers. Harefuah. 2014;153(12):747-51. (Review article). View the reference
Salvarani C, Silingardi M, Ghirarduzzi A, Lo Scocco G, Macchioni P, Bajocchi G, et al. Is duplex ultrasonography useful for the diagnosis of giant-cell arteritis? Ann Intern Med. 2002;137(4):232-8. (Level II evidence). View the reference
Tan E-K, Lim S-H, Chan L, Wong Z-W. Trigeminal neuralgia: should MRI be done routinely? Trigeminal neuralgia: should MRI be done routinely? View the reference
Chun-Cheng Q, Qing-Shi Z, Ji-Qing Z, Zhi-Gang W. A single-blinded pilot study assessing neurovascular contact by using high-resolution MR imaging in patients with trigeminal neuralgia. Eur J Radiol. 2009;69(3):459-63. (Level II evidence). View the reference
Goh BT, Poon CY, Peck RH. The importance of routine magnetic resonance imaging in trigeminal neuralgia diagnosis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92(4):424-9. (Level III evidence). View the reference
Masuda Y. Diagnosis and treatment of trigeminal neuralgia. Nihon Rinsho. 2001;59(9):1722-6. (Review article). View the reference
Schievink WI. Spontaneous dissection of the carotid and vertebral arteries. N Engl J Med. 2001;344(12):898-906. (Review article). View the reference
Haneline MT, Rosner AL. The etiology of cervical artery dissection. Journal of Chiropractic Medicine. 2007;6(3):110-20. (Review article). View the reference
Mashhood A, Kim P, Almaguel F, McWilliams G, Jacobson JP. Cerebral Misery Perfusion on Susceptibility Weighted Imaging in Acute Carotid Dissection. J Radiol Case Rep. 2016;10(10):1-6. (Review article). View the reference
Vertinsky AT, Schwartz NE, Fischbein NJ, Rosenberg J, Albers GW, Zaharchuk G. Comparison of multidetector CT angiography and MR imaging of cervical artery dissection. AJNR Am J Neuroradiol. 2008;29(9):1753-60. (Level III evidence). View the reference
Elijovich L, Kazmi K, Gauvrit JY, Law M. The emerging role of multidetector row CT angiography in the diagnosis of cervical arterial dissection: preliminary study. Neuroradiology. 2006;48(9):606-12 View the reference
Provenzale JM, Sarikaya B. Comparison of test performance characteristics of MRI, MR angiography, and CT angiography in the diagnosis of carotid and vertebral artery dissection: a review of the medical literature. AJR Am J Roentgenol. 2009;193(4):1167-74. (Review article). View the reference
Bonneville F. Imaging of cerebral venous thrombosis. Diagn Interv Imaging. 2014;95(12):1145-50. (Review article). View the reference
Lee SK, terBrugge KG. Cerebral venous thrombosis in adults: the role of imaging evaluation and management. Neuroimaging Clin N Am. 2003;13(1):139-52. (Review article). View the reference
Tsai FY, Wang AM, Matovich VB, Lavin M, Berberian B, Simonson TM, et al. MR staging of acute dural sinus thrombosis: correlation with venous pressure measurements and implications for treatment and prognosis. AJNR Am J Neuroradiol. 1995;16(5):1021-9. (Level III evidence). View the reference
Saba L, Anzidei M, Piga M, Ciolina F, Mannelli L, Catalano C, et al. Multi-modal CT scanning in the evaluation of cerebrovascular disease patients. Cardiovasc Diagn Ther. 2014;4(3):245-62. (Review article). View the reference
Khandelwal N, Agarwal A, Kochhar R, Bapuraj JR, Singh P, Prabhakar S, et al. Comparison of CT venography with MR venography in cerebral sinovenous thrombosis. AJR Am J Roentgenol. 2006;187(6):1637-43. (Level III evidence). View the reference
Connor SE, Jarosz JM. Magnetic resonance imaging of cerebral venous sinus thrombosis. Clin Radiol. 2002;57(6):449-61. (Review article). View the reference
Dormont D, Anxionnat R, Evrard S, Louaille C, Chiras J, Marsault C. MRI in cerebral venous thrombosis. J Neuroradiol. 1994;21(2):81-99. (Level III evidence). View the reference
Forbes KP, Pipe JG, Heiserman JE. Evidence for cytotoxic edema in the pathogenesis of cerebral venous infarction. AJNR Am J Neuroradiol. 2001;22(3):450-5. (Level III evidence). View the reference

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The relative radiation level (RRL) of each imaging investigation is displayed in the pop up box.

SYMBOL	RRL	EFFECTIVE DOSE RANGE
	None	0
	Minimal	< 1 millisieverts
	Low	1-5 mSv
	Medium	5-10 mSv
	High	>10 mSv

Disclaimer

Status Of Recommendations Each pathway is designed to assist clinicians in situations when faced with a large array of possible diagnostic tests and examinations. However, it is recognised that diagnostic practice may differ from a particular pathway depending on local availability of equipment and expertise, as well as the experience of individual clinicians. Therefore each pathway is neither a rigid set of rules, nor a substitute for clinical assessment, and individual patient circumstances should always be considered.

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Panning

Computed Tomography (CT)

Computed Tomography (CT) and Magnetic Resonance (MR) techniques are both useful in the investigation of craniocervical arterial dissections

Once thought to be a rare cause of ischaemic stroke. However, dissection is a major cause of stroke in young and middle aged patients, accounting for 10-25% of cases. (18) The overall incidence is 2-2.5 per 100 000 for spontaneous carotid artery dissection, and 1-1.5 per 100 000 for vertebral artery dissection in US and French populations
Spontaneous dissection of the carotid & vertebral arteries usually arise from an intimal tear. Blood enters the wall of the artery forming an intramural haematoma, which may result in stenosis of the arterial lumen resulting in an ischaemic insult to the brain or brainstem
Clinical features that may suggest arterial dissection include
- Carotid artery dissection: Initial presenting symptom is pain. Typically pain is unilateral facial, orbital or neck (upper anterolateral). It may present gradually or acutely, and is generally a constant steady ache. After several days (median 4), patients may develop neurological symptoms such as partial Horner's syndrome (miosis, ptosis), cranial nerve palsies of the lower cranial nerves (particularly hypoglossal), pulsatile tinnitus or transient ischaemic attacks
- Vertebral artery dissection: Pain is the initial presenting symptom. Pain is less distinct than with carotid artery dissection and can often be mistaken for musculoskeletal pain. Pain may be localised to the back of neck or occiput, unilaterally or bilaterally. Nature of pain can be steady or throbbing. After (median) 2 weeks, patients may develop neurological symptoms such as lateral medullary syndrome, unilateral pain or weakness of an arm
Conventional angiography has long been the gold standard for diagnosing arterial dissections. However, it has some important limitations. It is an invasive test, and carries additional risks compared with non-invasive imaging. Also, it cannot demonstrate intramural haematomas
Non-invasive imaging (particularly MRI and CT) is commonly used to investigate headaches and partially accounts for the increased recognition and diagnosis of craniocervical arterial dissections
There are a few small head-to-head studies comparing MRI/MRA to MDCT/CTA for evaluating craniocervical arterial dissections. Elijovich et al. used a retrospective series of 7 patients, and found that 7/7 dissections were diagnosed on CTA vs 5/7 for MRI/MRA. Vertinsky et al. used 18 retrospective cases and found that MDCT was able to visualise more features of cervical & vertebral artery dissection and was generally preferred over MR imaging by the reviewing neuroradiologists
A review of 21 studies by Provenzale et al. suggested that MRI/MRA and CTA had similar test characteristics, and concluded that there was limited evidence to suggest the superiority of one technique over the other

Magnetic Resonance Imaging (MRI)

Computed Tomography (CT) and Magnetic Resonance (MR) techniques are both useful in the investigation of craniocervical arterial dissections

Once thought to be a rare cause of ischaemic stroke. However, dissection is a major cause of stroke in young and middle aged patients, accounting for 10-25% of cases. (18) The overall incidence is 2-2.5 per 100 000 for spontaneous carotid artery dissection, and 1-1.5 per 100 000 for vertebral artery dissection in US and French populations
Spontaneous dissection of the carotid & vertebral arteries usually arise from an intimal tear. Blood enters the wall of the artery forming an intramural haematoma, which may result in stenosis of the arterial lumen resulting in an ischaemic insult to the brain or brainstem
Clinical features that may suggest arterial dissection include
- Carotid artery dissection: Initial presenting symptom is pain. Typically pain is unilateral facial, orbital or neck (upper anterolateral). It may present gradually or acutely, and is generally a constant steady ache. After several days (median 4), patients may develop neurological symptoms such as partial Horner's syndrome (miosis, ptosis), cranial nerve palsies of the lower cranial nerves (particularly hypoglossal), pulsatile tinnitus or transient ischaemic attacks
- Vertebral artery dissection: Pain is the initial presenting symptom. Pain is less distinct than with carotid artery dissection and can often be mistaken for musculoskeletal pain. Pain may be localised to the back of neck or occiput, unilaterally or bilaterally. Nature of pain can be steady or throbbing. After (median) 2 weeks, patients may develop neurological symptoms such as lateral medullary syndrome, unilateral pain or weakness of an arm
Conventional angiography has long been the gold standard for diagnosing arterial dissections. However, it has some important limitations. It is an invasive test, and carries additional risks compared with non-invasive imaging. Also, it cannot demonstrate intramural haematomas
Non-invasive imaging (particularly MRI and CT) is commonly used to investigate headaches and partially accounts for the increased recognition and diagnosis of craniocervical arterial dissections
There are a few small head-to-head studies comparing MRI/MRA to MDCT/CTA for evaluating craniocervical arterial dissections. Elijovich et al. used a retrospective series of 7 patients, and found that 7/7 dissections were diagnosed on CTA vs 5/7 for MRI/MRA. Vertinsky et al. used 18 retrospective cases and found that MDCT was able to visualise more features of cervical & vertebral artery dissection and was generally preferred over MR imaging by the reviewing neuroradiologists
A review of 21 studies by Provenzale et al. suggested that MRI/MRA and CTA had similar test characteristics, and concluded that there was limited evidence to suggest the superiority of one technique over the other

Computed Tomography (CT)

Computed Tomography Venogram (CTV) is an alternative to Magnetic Resonance Venogram (MRV) for investigation of cerebral venous thrombosis

Has a highly variable and non specific presentation from thunderclap headache to symptoms of raised cerebral venous pressure such as headache, vomiting and papilloedema
Imaging findings can be direct when the thrombus is visible within the cerebral venous system or indirect when there are ischaemic changes related to the venous outflow obstruction
The combination of MRI and magnetic resonance venography (MRV) is the imaging modality of choice for the investigation of suspected CVT
CT Venography (CTV) is a viable alternative to MRV in the examination of patients with suspected dural sinus thrombosis especially in acute settings
The CTV is not affected by flow-related artefacts and is considered superior to MRV in identification of cerebral veins (particularly smaller ones with slow flow) and sinuses and at least equivalent to MRI/MRV in the diagnosis of of cerebral venous sinus thrombosis (CVST)
CTV also has the advantage that it may be used in the uncooperative patient as acquisition times are only approximately 1 min and is useful when MRI is contraindicated
MR techniques have the benefit of avoiding intravenous contrast and ionising radiation and are more sensitive than CT to cerebral parenchymal changes which are present in 40-70% patients with CVST
On pre-contrast CT the acute thrombus may be visible as an elongated high attenuation lesion within the dural sinus or cortical vein - the cord sign or dense triangle sign
On post-contrast images a filling defect may be seen as the dura enhances but the thrombus does not - the empty delta sign
On MRI acute thrombus is isointense to brain on T1-weighted images and hypointense on T2-weighted images. Between 3 and 7 days after thrombus formation the clot becomes hyperintense on T-1 weighted images and is easier to recognize but this may interfere with time of flight MRV studies
MRI is also sensitive to the parenchyma and haemorrhagic changes of venous infarction. High signal intensity lesions on fluid-attenuated inversion-recovery sequence and T2-weighted imaging that do not correspond to an arterial territory may suggest CVT

Magnetic Resonance Imaging (MRI)

Magnetic Resonance Imaging (MRI) and Magnetic Resonance Venogram (MRV) are the imaging modalities of choice for suspected cerebral venous thrombosis

Has a highly variable and non specific presentation from thunderclap headache to symptoms of raised cerebral venous pressure such as headache, vomiting and papilloedema
Imaging findings can be direct when the thrombus is visible within the cerebral venous system or indirect when there are ischaemic changes related to the venous outflow obstruction
The combination of MRI and magnetic resonance venography (MRV) is the imaging modality of choice for the investigation of suspected CVT
CT Venography (CTV) is a viable alternative to MRV in the examination of patients with suspected dural sinus thrombosis especially in acute settings
The CTV is not affected by flow-related artefacts and is considered superior to MRV in identification of cerebral veins (particularly smaller ones with slow flow) and sinuses and at least equivalent to MRI/MRV in the diagnosis of of cerebral venous sinus thrombosis (CVST)
CTV also has the advantage that it may be used in the uncooperative patient as acquisition times are only approximately 1 min and is useful when MRI is contraindicated
MR techniques have the benefit of avoiding intravenous contrast and ionising radiation and are more sensitive than CT to cerebral parenchymal changes which are present in 40-70% patients with CVST
On pre-contrast CT the acute thrombus may be visible as an elongated high attenuation lesion within the dural sinus or cortical vein - the cord sign or dense triangle sign
On post-contrast images a filling defect may be seen as the dura enhances but the thrombus does not - the empty delta sign
On MRI acute thrombus is isointense to brain on T1-weighted images and hypointense on T2-weighted images. Between 3 and 7 days after thrombus formation the clot becomes hyperintense on T-1 weighted images and is easier to recognize but this may interfere with time of flight MRV studies
MRI is also sensitive to the parenchyma and haemorrhagic changes of venous infarction. High signal intensity lesions on fluid-attenuated inversion-recovery sequence and T2-weighted imaging that do not correspond to an arterial territory may suggest CVT

Headache (Adult, Recent Onset)