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  • Updated 07.06.2024
  • Released 12.11.2000
  • Expires For CME 07.06.2027

Neuroimaging of headache



Although usually benign, headache can herald serious intracranial disease. Neuroimaging must be considered whenever secondary causes of headache are suspected. This review focuses on indications for neuroimaging in clinical practice and the contribution that neuroimaging has made to our understanding of headache pathophysiology. 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 as well as neuroimaging findings in patients headache related to COVID-19.

Key points

• Most patients with headache do not need neuroimaging.

• Use “red flags” based on history and exam findings to determine the necessity of neuroimaging.”

• Although neuroimaging is usually normal in patients with migraine, unusual primary headaches such as trigeminal autonomic cephalalgias or cough headache may be an exception.

Historical note and terminology

Headache diagnosis is clinical, based on a careful history and physical exam (51). The International Headache Society Classification defines headaches as primary, based on their clinical features or genetic markers, or secondary due to another proven cause (43). For primary headache disorders such as migraine, diagnosis does not rely on neuroimaging.

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