“Worst Headache of Life” in a Migraineur: Marginal Value of Emergency Department CT Scanning

Sadaf Sahraian, Elham Beheshtian, Arya Haj-Mirzaian, Matthew D. Alvin, David Mark Yousem

Research output: Contribution to journalArticle

Abstract

Purpose: The ACR Appropriateness Criteria recommend performing noncontrast head CT (NCCT) for patients with sudden severe headache (“worst headache of life” [WHOL] or “thunderclap headache” [TCH]). The aim of this study was to assess the value of NCCT scanning in patients with known migraine histories and WHOL or TCH. The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH. Methods: The ED NCCT scans of all patients reporting WHOL or TCH who had established diagnoses of migraine were retrospectively reviewed over a 5-year period. Patients without known intracranial pathology, cancer, or immunocompromising disease or recent head trauma were included as the main study group. For comparison, patients with any of those factors were included as the comparison group. Scans were graded as (1) normal, (2) minor unimportant findings, (3) findings requiring intervention or follow-up, or (4) critical. Results: Two hundred twenty-four patients with the chief symptom of WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In the main study group, no patients had grade 4 imaging findings (0%), one had a false-positive grade 3 finding (0.8%), and there were no cases of subarachnoid hemorrhage (0%). In the comparison group, six patients had grade 4 imaging findings (6.5%) and three had grade 3 findings (3.3%). Conclusions: NCCT in known migraineurs with WHOL or TCH who do not have intracranial pathology, cancer, immunocompromising disease, or recent head trauma yielded no critical findings. Therefore, the value of scanning these patients is questionable.

Original languageEnglish (US)
JournalJournal of the American College of Radiology
DOIs
StateAccepted/In press - Jan 1 2019

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Primary Headache Disorders
Headache
Hospital Emergency Service
Head
Migraine Disorders
Craniocerebral Trauma
Pathology
Subarachnoid Hemorrhage
Neoplasms

Keywords

  • CT
  • Headache
  • migraine
  • subarachnoid hemorrhage

ASJC Scopus subject areas

  • Radiology Nuclear Medicine and imaging

Cite this

“Worst Headache of Life” in a Migraineur : Marginal Value of Emergency Department CT Scanning. / Sahraian, Sadaf; Beheshtian, Elham; Haj-Mirzaian, Arya; Alvin, Matthew D.; Yousem, David Mark.

In: Journal of the American College of Radiology, 01.01.2019.

Research output: Contribution to journalArticle

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abstract = "Purpose: The ACR Appropriateness Criteria recommend performing noncontrast head CT (NCCT) for patients with sudden severe headache (“worst headache of life” [WHOL] or “thunderclap headache” [TCH]). The aim of this study was to assess the value of NCCT scanning in patients with known migraine histories and WHOL or TCH. The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH. Methods: The ED NCCT scans of all patients reporting WHOL or TCH who had established diagnoses of migraine were retrospectively reviewed over a 5-year period. Patients without known intracranial pathology, cancer, or immunocompromising disease or recent head trauma were included as the main study group. For comparison, patients with any of those factors were included as the comparison group. Scans were graded as (1) normal, (2) minor unimportant findings, (3) findings requiring intervention or follow-up, or (4) critical. Results: Two hundred twenty-four patients with the chief symptom of WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In the main study group, no patients had grade 4 imaging findings (0{\%}), one had a false-positive grade 3 finding (0.8{\%}), and there were no cases of subarachnoid hemorrhage (0{\%}). In the comparison group, six patients had grade 4 imaging findings (6.5{\%}) and three had grade 3 findings (3.3{\%}). Conclusions: NCCT in known migraineurs with WHOL or TCH who do not have intracranial pathology, cancer, immunocompromising disease, or recent head trauma yielded no critical findings. Therefore, the value of scanning these patients is questionable.",
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AB - Purpose: The ACR Appropriateness Criteria recommend performing noncontrast head CT (NCCT) for patients with sudden severe headache (“worst headache of life” [WHOL] or “thunderclap headache” [TCH]). The aim of this study was to assess the value of NCCT scanning in patients with known migraine histories and WHOL or TCH. The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH. Methods: The ED NCCT scans of all patients reporting WHOL or TCH who had established diagnoses of migraine were retrospectively reviewed over a 5-year period. Patients without known intracranial pathology, cancer, or immunocompromising disease or recent head trauma were included as the main study group. For comparison, patients with any of those factors were included as the comparison group. Scans were graded as (1) normal, (2) minor unimportant findings, (3) findings requiring intervention or follow-up, or (4) critical. Results: Two hundred twenty-four patients with the chief symptom of WHOL or TCH and a history of migraine who underwent ED NCCT were studied. In the main study group, no patients had grade 4 imaging findings (0%), one had a false-positive grade 3 finding (0.8%), and there were no cases of subarachnoid hemorrhage (0%). In the comparison group, six patients had grade 4 imaging findings (6.5%) and three had grade 3 findings (3.3%). Conclusions: NCCT in known migraineurs with WHOL or TCH who do not have intracranial pathology, cancer, immunocompromising disease, or recent head trauma yielded no critical findings. Therefore, the value of scanning these patients is questionable.

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