Imaging in Chronic Migraine

Diagnostic Yield and Indications

The rate of finding serious intracranial abnormalities in patients with chronic headache and normal neurological examination is only 0.5% (95% CI: 0.2-1.0%), which is comparable to the 0.4% rate of incidental findings in completely asymptomatic volunteers 1
For migraine patients specifically with normal neurological examination, the rate of serious abnormality is even lower at 0.2% (95% CI: 0.02-0.7%) 1
Neuroimaging is not usually warranted for patients with migraine and normal neurological examination 1
New or unexplained abnormal neurological findings on examination significantly increase the probability of finding intracranial pathology 1
A change in headache pattern, particularly if headaches are progressively worsening, have new characteristics, or show orthostatic features, may indicate the need for repeat imaging 2, 3, 4
Severe or worsening headache that is refractory to appropriate medical management may require repeat imaging 5

Consider multidisciplinary evaluation if headaches remain refractory to initial prophylactic treatment 5