Migraine is extremely common, with a lifetime incidence of 43% in women and 18% in men, and a median age of onset of 24-5.
The vast majority of headache patients have migraine and need a careful history & physical examination, followed by appropriate treatment, not a brain imaging study.
Furthermore, there are potential complications involved with brain imaging: Some patients are claustrophobic and require sedation, even a general anesthetic. Many “abnormalities” are innocuous, unrelated to the headache and do not require treatment. However, these headache patients with such “incidentalomas” are left with the conclusion that there is something wrong with them, and may be subjected to further unnecessary follow-up studies. A few end up getting unnecessary invasive tests, which actually hurt them.
However, not a day goes past without a migraine patient asking me for a brain imaging study, or for that matter a patient referred to the office worried about an “incidentaloma” identified on a brain imaging study which should never have been done in the first place.
That’s not to say brain imaging is always unnecessary in every headache patient.
Carefully selected patients with the following “red flag” characteristics might still need a scan:
This approach is supported by the American Academy of Neurology, whose position is that neuroimaging usually is not warranted for patients with migraine and normal neurologic examination, only for patients with atypical headache features.