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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.

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 guide is for informational purposes only and does not constitute medical or legal advice, and is not intended for use in the diagnosis or treatment of individual conditions. The guide is not comprehensive and is provided as an example only, and should not be used as a substitute for the exercise of professional judgment, including but not limited to, in connection with any billing, imaging, CPT or other orders or healthcare claims related matter. The mention of any test, protocol, product, service, organization, activity, or therapy should not be construed as an endorsement by Johns Hopkins or its affiliates. This information is provided without representations or warranties of any kind, express or implied, all of which are disclaimed. Johns Hopkins and its affiliates assume no responsibility for any injury or damage to persons or property, delays or loss of revenue/income arising out of or related to the guide.