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eEdE-215
Appropriate Imaging
of Headache
Young Park, MD
Vinh Nguyen, MD
Department of Radiology
Hofstra Northwell School of Medicine
LIJ Medical Center
New Hyde Park, NY
• Neither the authors nor their immediate family members have
a financial relationship with a commercial organization that
may have a direct or indirect interest in the content.
Index Case
• 50 y/o M in ED p/w headache
• Reason for CT: “Headache,
Thunderclap, Worst HA of Life”
Overview
• Background
• Indications for imaging
• Cases
• ICD-10
Overview
• Background
• Utilization and cost
• Common primary headache syndromes
• Indications for imaging
• Cases
• ICD-10
Headache
• One of the most common human ailments
• Overall lifetime prevalence up to 60% in adults, up to 83% in children
• Most common between age 25-55 years
• Muscle contraction or tension accounts for most nonmigraine
headaches
• Common clinical concerns referred for imaging
• Brain tumor (49%)
• Subarachnoid hemorrhage (9%)
• Patient expectation or medicolegal (17%)
ACR Appropriateness Criteria – Headache (2013)
Utilization and Cost
• High utilization of neuroimaging for nontraumatic headache (HA)
• Annual cost ~$1 billion, increasing
• 1998-2008, utilization in the ED increased from 12.5%  31%
• Yield of significant intracranial pathology decreased from 10.1%  3.5%
• Increased length of ED stay with imaging
• High frequency of HA + low yield studies  high false positives
• Cost to detect a lesion
• 0.4% yield of positive studies for imaging isolated, nontraumatic HA2
• $100,000 with CT (~$400/scan)
• $225,000 with MRI (~$900/scan)
1. Gilbert JW. Emerg Med J. 2012;29(7):576-581.
2. ACR Appropriateness Criteria – Headache (2013)
ACR Recommendations
Multiple studies have shown that the
rate of significant intracranial
pathology found on “routine”
headache imaging is the same as that
for a randomly chosen group of nonheadache patients (1-3%)
Common Primary HA Syndromes
• Migraine
• Nausea
• Exacerbation by physical
activity
• Photo/phonophobia
• Visual auras
• Family history of migraine
>50%
• Tension-type
•
•
•
•
Recurring bandlike pressing HA
Can be throbbing or unilateral
Few migrainous features
Stress or hunger trigger >50%
Smetana GW. Arch Intern Med. 2000;160:2729-2737.
• Cluster
•
•
•
•
Strictly unilateral
Duration < 3 hours
Periorbital location
Ipsilateral lacrimation and
rhinorrhea most common
assoc. autonomic symptoms
• 6x more common in men
• Historical features can help
confidently diagnose these
syndromes without additional
evaluation
Overview
• Background
• Indications for imaging
• Clinical features
• ACR Appropriateness Criteria
• Clinical decision support
• Cases
• ICD-10
Clinical Features: Red Flags
• Onset of new or different
headache
• Nausea or vomiting
• Worst headache ever experience
• Progressive visual or
neurological changes
• Paralysis
• Weakness, ataxia or loss of coordination
• Drowsiness, confusion, memory
impairment or loss of
consciousness
• Onset of headache after age of
50 years
Sobri M, et al. Br J Radiol. 2003;76:532-535.
• Papilledema
• Stiff neck
• Onset of headache with exertion,
sexual activity or coughing
• Systemic illness
• Numbness
• Asymmetry of pupillary response
• Sensory loss
• Signs of meningeal irritation
Clinical Features: Red Flags
• Three with high positive
predictive value (p < 0.05)
• Onset of paralysis
• Papilledema
• Drowsiness, confusion,
memory impairment or LOC
• Presence of three “red flags”
provided optimum sensitivity
and specificity in Sobri M, et
al.
Sobri M, et al. Br J Radiol. 2003;76:532-535.
Receiver operating characteristic (ROC) curve. This graph plots
sensitivity vs. 1-specificity giving rise to ROC curve. The graph
shows area under the curve=0.76. Red flag=3 (point=0.62)
represents the cut-off point (both sensitivity and specificity are
optimum derived from specificity and sensitivity 2x2 table).
ACR Appropriateness Criteria
Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate
• Chronic HA, no new features,
normal neuro exam
MRI head wo/w or wo
CT head wo, wo/w, or w
• Chronic HA with new features
or neuro deficit
MRI head wo/w
MRI or CT head wo
CT head w
• Sudden onset severe HA
CT head wo
CTA head w
MRA head wo/w or wo
• New HA in cancer patient or
immunocompromised
MRI head wo/w
MRI head wo
CT head wo/w or w
• New HA in pregnant woman
MRI head wo
CT head wo
MRV or MRA head wo
• New HA with focal neuro deficit
or papilledema
MRI head wo/w
MRI or CT head wo
Clinical Decision Support
• Provides real-time feedback to providers ordering imaging
tests
• Test appropriateness for specific indications
• Alternatives if imaging not indicated
• JACR 2011 study, Virginia Mason Medical Center, Seattle1
• 2005-2009 CDS implemented for lumbar MRI for LBP, head MRI for
HA and sinus CT for sinusitis
• Rates of imaging all decreased by 23-27% rate of head CT (control)
stable
• Starting 1/1/2017, CMS will withhold payment unless use of
CDS is documented
• New era of Medicare payment modification based on quality and
value
1. Blackmore CC, et al. J Am Coll Radiol. 2011;8:19-25.
Overview
• Background
• Indications for imaging
• Clinical features
• ACR Appropriateness Criteria
• Clinical decision support
• Cases
• ICD-10
Index Case
• 50 y/o M p/w headache
• H&P: Woke up with first time, 10/10
bifrontal headache, N/V photophobia
Case 2
• 28 y/o F “Headache. Evaluate for mass.
Difficulty ambulating. History of seizures.”
Case 2
• H&P: HA, progressive right
hemiparesis, 3 days complex partial
seizures
• Hx of neuroblastoma s/p resection 20
years ago
• Whole brain radiation and
chemotherapy
• History of seizures
• Underwent resection of tumor...
Case 3 • 19 y/o F “HA, Thunderclap, Worst HA of Life”
Case 3
• H&P: 19 y/o F p/w headache, nausea/vomiting lethargy
since this AM
• Family history: patient’s father died of a ruptured aneurysm
Case 4
• 54 y/o M “2 weeks of headache and memory
loss, evaluate for tumor”
Case 4
• H&P: 54 y/o M with new frontal
headache and memory loss
for 2 weeks
• Primary malignancy workup
inconclusive
• Underwent partial resection…
Case 5
• 24 y/o F “headache after epidural catheter for
delivery”
Case 5
• H&P: 24 y/o F with frequent
moderate to severe HA
• Status post C-section 6 days
ago
• Dx consistent with history,
patient underwent epidural
blood patch
• HA resolved within 2 days
Case 6
• H&P: 17 y/o M with h/o AML,
presenting with AMS
headache, new onset seizures
• Small right and trace left
subdural collections
Case 6
• H&P: 17 y/o M with h/o AML,
presenting with AMS
headache, new onset seizures
• Small right and trace left
subdural collections
• Smooth leptomeningeal
enhancement
Case 6
• H&P: 17 y/o M with h/o AML,
presenting with AMS
headache, new onset seizures
• Small right and trace left
subdural collections
• Smooth leptomeningeal
enhancement
• Sagging brainstem,
effacement of prepontine
cistern, descent of cerebellar
tonsils
Case 7
• H&P: 50 y/o F, recent minor
head trauma, headache
• Sagging optic chiasm
Normal comparison
Overview
• Background
• Indications for imaging
• Clinical features
• ACR Appropriateness Criteria
• Clinical decision support
• Cases
• ICD-10
ICD-10 Changes
• 784.0
• Headache NOS
• Daily chronic
• Nasal septum
• Vascular
• R51
• Headache NOS
• Daily chronic
• Nasal septum
• G44.1
• Vascular headache, not
elsewhere classified
ICD-10 Changes
• 307.81
•
•
•
•
•
Tension
Emotional
Nonorganic origin
Psychogenic
Psychophysiologic
• 627.2
• Menopausal headache
• G44.209
• Tension
• Not intractable
• Intractable
• Other 4 conditions not listed in
ICD-10
• Menopausal headache has
no unique code in ICD-10
Coding Headache
• ICD-9 code 784.0 (headache) made up 1-2% of annual code
population
• Among top 10 dx codes worked up in ED
• 784.0 and 346.0 (migraine) most often used when coding for
headache
• Documentation could have been more specific
• Reimbursement may eventually be adjusted for specificity of coding
http://www.mckesson.com/bps/bps-knowledge-center/icd-9-to-icd-10-documentation-for-headache/
Summary
• Imaging uncomplicated HA is costly and substantially
overused with little evidence to justify cost
• Historical features can diagnose common primary HA
syndromes without further evaluation
• Recognize red flags to prompt imaging workup and refer to
ACR Appropriateness Criteria to guide testing
• Clinical information is essential for appropriate imaging and
accurate interpretation
References
• ACR Appropriateness Criteria – Headache (2013)
• Blackmore CC, et al. Effectiveness of Clinical Decision Support in Controlling
Inappropriate Imaging. J Am Coll Radiol. 2011;8:19-25.
• Callaghan BC, et al. Headaches and Neuroimaging: High Utilization and Costs
Despite Guidelines. JAMA Intern Med. 2014;174(5):819-821.
• Gilbert JW. Atraumatic headache in US emergency departments: recent trends in
CT/MRI utilisation and factors associated with severe intracranial pathology. Emerg
Med J. 2012;29(7):576-581.
• Smetana GW. The Diagnostic Value of Historical Features in Primary Headache
Syndromes, A Comprehensive Review. Arch Intern Med. 2000;160:2729-2737.
• Sobri M, et al. Red flags in patients presenting with headache: clinical indications for
neuroimaging. Br J Radiol. 2003;76:532-535.
• Tsushima Y, Endo K. MR Imaging in the Evaluation of Chronic or Recurrent Headache.
Radiology. 2005;235:575-579.