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 eEdE-215

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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 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 1. Gilbert JW. Emerg Med J. 2012;29(7): ACR Appropriateness Criteria – Headache (2013)

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 non- headache patients (1-3%) ACR Recommendations

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% 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 Smetana GW. Arch Intern Med. 2000;160:

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 co- ordination 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: 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 Sobri M, et al. Br J Radiol. 2003;76: 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). 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.

ACR Appropriateness Criteria New HA in cancer patient or immunocompromised 9: MRI head wo/w 7: MRI head wo 6: CT head wo/w or w New HA in pregnant woman 8: MRI head wo 7: CT head wo 6: MRV or MRA head wo New HA with focal neuro deficit or papilledema 8: MRI head wo/w 7: MRI or CT head wo Rating Scale: 1,2,3 Usually not appropriate; 4,5,6 May be appropriate; 7,8,9 Usually appropriate

Clinical Decision Support 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

Case 2 28 y/o F “Headache. Evaluate for mass. Difficulty ambulating. History of seizures.”

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 2

Case 3 19 y/o F “HA, Thunderclap, Worst HA of Life”

Case 3

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

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 Headache NOS Daily chronic Nasal septum Vascular R51 Headache NOS Daily chronic Nasal septum G44.1 Vascular headache, not elsewhere classified

ICD-10 Changes Tension Emotional Nonorganic origin Psychogenic Psychophysiologic Menopausal headache G 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 (headache) made up 1-2% of annual code population Among top 10 dx codes worked up in ED and (migraine) most often used when coding for headache Documentation could have been more specific Reimbursement may eventually be adjusted for specificity of coding

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: Callaghan BC, et al. Headaches and Neuroimaging: High Utilization and Costs Despite Guidelines. JAMA Intern Med. 2014;174(5): 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): Smetana GW. The Diagnostic Value of Historical Features in Primary Headache Syndromes, A Comprehensive Review. Arch Intern Med. 2000;160: Sobri M, et al. Red flags in patients presenting with headache: clinical indications for neuroimaging. Br J Radiol. 2003;76: Tsushima Y, Endo K. MR Imaging in the Evaluation of Chronic or Recurrent Headache. Radiology. 2005;235: