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Johns Hopkins Medical Imaging

Headaches: Imaging Appropriateness Criteria

doctor ordering exam

Headaches are a common complaint among patients, with many caused by tension or chronic migraines. Many headaches can be clinically diagnosed through imaging. Details on the most appropriate imaging exam to order based on suspected diagnosis or symptom, as well as red flags that necessitate ordering imaging, are below.

You can also watch a lecture on appropriate imaging for headaches by Johns Hopkins neuroradiologist Sachin Gujar, presented at a previous Order Wisely CME course.

Red Flags that Support Imaging for Headache

  • Abnormal neurological examination (e.g. papilledema, altered mental status).
  • Signs of systemic illness (e.g., fever, stiff neck, rash).
  • Worst headache ever.
  • Progression in frequency and severity of headaches.
  • New headache in patients older than 50 years.
  • Sudden onset of headache – “thunderclap headache.”
  • New-onset headache in an immunocompromised or cancer patient.
  • Headache after head trauma.
  • Headache worsening with Valsalva.

Imaging Ordering Guidelines for Headache

Nontraumatic Headache

Noncontrast CT

  • Sudden onset of severe headache ("thunderclap").
  • Worst head of life.

MR preferred over CT

  • New headache with focal neurological deficit or papilledema.
  • Pain of trigeminal autonomic origin.
  • Skull base, orbital or periorbital pain.
  • Suspect complications of sinusitis.
  • New headache in elderly patient.
  • New headache in immune-compromised or cancer patient.
  • New headache, suspect meningitis and/or encephalitis.
  • Positional headache (MRI>>CT).
  • Headache exacerbated by cough or exertion.
  • New headache in pregnant patient (no contrast).

CTA head & neck with IV contrast or MRA head & neck with IV contrast

  • Suspect carotid or vertebral artery dissection.
  • Ipsilateral Horner sundrome.
  • Initial head CT shows acute intracranial hemorrhage with suspected vascular etiology (aneurysm, high flow vascular malformation).

Traumatic Headache

  • CT without contrast most appropriate in acute setting.
  • For suspected diffuse axonal injury or subacute trauma, include susceptibility (weighted) sequences when ordering MRI.

Order Wisely®: Appropriate Use of Tests & Treatments

A leading principle of high-value health care is the avoidance of unnecessary tests and treatments in accordance with established clinical practice guidelines. To reinforce this practice, we provide multiple educational resources that review appropriate use of imaging exams. An understanding of the evidence behind appropriate ordering is important to improve long-standing practice habits and overcome concerns about missed diagnoses. Content includes best imaging exam selection for the eight CMS priority clinical areas to ensure that providers are prepared for the CMS Appropriate Use Program.

Learn more about the Johns Hopkins University School of Medicine Appropriate Use Criteria Program.

Additional Resources

Access FREE recordings of lectures from prior Order Wisely® conferences.

For more information, see “Imaging for Headache: Red Flags and Modalities” at the “Order Wisely – Ambulatory Care” track at the 5th annual Architecture of High Value Health Care national conference on October 6, 2022.

This work is intended for use to assist hospital and healthcare audiences; however, Johns Hopkins makes no representations or warranties concerning the content or clinical efficacy of this work, its accuracy or completeness. Johns Hopkins is not responsible for any errors or omissions or for any bias, liability or damage resulting from the use of this work. This work is not intended to be a substitute for professional judgment, advice or individual root cause analysis.