An ongoing debate over whether ED CTs are required for migraine or severe headache is still unfruitful. Even though the American College of Radiology (ACR) Appropriateness Criteria Variant 3 recommends Non-contrast Head CT (NCCT) to some patients with sudden headache or a severe migraine, there is a question about whether it is necessary.

Sudden headache may happen to patients. However, it is important to consider if there are any high-risk factors or other ailments that could be life-threatening. Researchers at the Johns Hopkins Medical Centre, Baltimore, Maryland found that it is not necessary to perform emergency department (ED) NCCT scans on patients complaining of a sudden and severe headache.

The Study

For the purpose of the study, the research team reviewed some ED NCCT scans that were conducted over a period of 5 years in 224 patients having a medical history of TCH or WHOL and diagnosed with migraine.

Patients were then divided into two groups based on their respective scan results. The groups comprised of 132 patients without any known medical history of intracranial pathology, immunocompromising disease, or cancer, or a recent head injury or trauma, and 92 patients with a positive medical history of any such factors to be compared.

Furthermore, experienced neurologists with over 30 years of practice graded the scan results. They categorized their findings as:

• Normal (1)
• Having minor findings (2) but unimportant
• Findings that required medical intervention and follow-up (3)
• Critical patients (4)

The results of the main study showed that no patients had grade 4 categories of imaging findings. However, one patient showed false-positive grade 3 finding, which is 0.8% of the total research. No cases of chronic subarachnoid hemorrhage were reported.

For comparison, six patients showed grade 4 findings, which is 6.5% and three showed grade 3 findings, which is 3.3%.

The Findings

As published in the Journal of the American College of Radiology on Jan 17, the study reveals that repetitive NCCT scans, when done on patients with severe headache or migraine – also called WHOL (worst headache of life) or TCH (thunderclap headache) –has limited value unless that patient has a medical history of recent trauma, cancer, or intracranial pathology.

The researchers also said that considering low yield of NCCT, it is crucial to reconsider the appropriateness criteria of ACR recommendation before scanning patients showing the red flag of WHOL, TCH or Variant.  It is also necessary to consider the population of chronic migraine patients.

Based on these findings, it is certain that imaging patients with severe headaches or migraine are not necessary. It should be limited to individuals who have never been imaged in the past.

If a patient with migraine shows negative image findings and TCH or WHOL, and there is a suspicion of subarachnoid hemorrhage, a lumbar puncture may be a better diagnostic tool.

Final Word

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