Neuroimaging of headache

Michael J Marmura MD (

Dr. Marmura of Thomas Jefferson University Hospital received research support from Allergan and Teva; honorariums from Alder, Antres Pharma, Promius, Supernus, and Theranica for consulting services; and honorariums from Amgen/Novartis, GammaCore, and Lilly for speaking engagements.

Stephen D Silberstein MD, editor. (

Dr. Silberstein, Director of the Jefferson Headache Center at Thomas Jefferson University, receives honorariums from Allergan, Avanir Pharmaceuticals, Curelator, Depomed, Dr. Reddy's Laboratories, eNeura,  INSYS Therapeutics, Lilly USA, Supernus Pharmacerticals,  Thernica and Trigemina for consulting. He is also the  principal investigator for a clinical trials conducted by Alder Biopharmaceuticals, Amgen, electroCore Medical, Lily USA and Teva.

Originally released December 11, 2000; last updated February 13, 2020; expires February 13, 2023


Although usually benign, headache can herald serious intracranial disease. Neuroimaging must be considered whenever secondary causes of headache are suspected. The authors discuss both the contribution that neuroimaging has made to our understanding of headache pathophysiology and the indications for neuroimaging in clinical practice. Common abnormalities on exam and their relationship to headache are explored, as well as the yield of neuroimaging in various clinical situations. Advances in imaging, such as functional MRI to study migraine pathophysiology, now demonstrate the role of the hypothalamus, brainstem structure, and network abnormalities. This review also highlights serious secondary causes of headache such as vascular disorders and tumors as a trigger for headache and, occasionally, cluster headache.

Key points


• Not all cases of headache require neuroimaging.


• When deciding whether or not to image a patient with headache, think about the “red flags.”


• Neuroimaging should be strongly considered in unusual primary headaches, such as the trigeminal autonomic cephalalgias, cough, or exertional headaches, etc.

Historical note and terminology

Headache diagnosis is clinical, based on a careful history and physical exam (Koehler 2001). The International Headache Society Classification defines headaches as primary, based on their clinical features or genetic markers, or secondary due to another proven cause (Headache Classification Subcommittee of the International Headache Society 2013). For primary headache disorders such as migraine, diagnosis does not rely on neuroimaging.

The content you are trying to view is available only to logged in, current MedLink Neurology subscribers.

If you are a subscriber, please log in.

If you are a former subscriber or have registered before, please log in first and then click select a Service Plan or contact Subscriber Services. Site license users, click the Site License Acces link on the Homepage at an authorized computer.

If you have never registered before, click Learn More about MedLink Neurology  or view available Service Plans.

Find out how you can join MedLink Neurology