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Clinical condition—Headache
CT, head, without contrast CT, head, without and with contrast MR imaging, brain, without and with contrast MR imaging, brain, without contrast MR angiography, head, with or without contrast CT angiogram, head Angiography, cerebral MR angiography, head and neck, with or without contrast CT angiogram, head and neck Worsened chronic headache. History of headache. 4 4 4 4 2 2 2 X X Sudden onset of severe headache (“Worst headache of one's life, thunderclap headache”). 9 6 6a 7a 8 8 7 X X Sudden onset of unilateral headache, or suspected carotid or vertebral dissection or ipsilateral Horner syndrome.o 8 6 8b 8b X X 7 8c 8c Headache, suspected complication of sinusitis and/or mastoiditis.p 7d 6d 8 7 X X X X X New headache in patient older than age 60. Sedimentation rate higher than 55, temporal tenderness. Suspected temporal arteritis. 6 5 7c 8c X X 4e 5 5 New headache in HIV+ individual. 6f 5 8 8 3g 3g 2e X X New headache in pregnant patient.q 8 X 5h 8 5i 2j X X X New headache. Suspected meningitis/encephalitis. 8k 6l 8 6m 6i 3n X X X Note:—Appropriateness criteria scale from 1 to 9, 1–least appropriate, 9–most appropriate;
a , may be helpful after CT depending on CT findings;
b , with diffusion-weighted sequences;
c , usage of CT versus MR imaging depends on local preference and availability;
d , include sinuses;
e , if noninvasive imaging unrewarding;
f , if MR imaging not available;
g , if vascular lesion suspected;
h , pregnancy is a relative contraindication to gadolinium administration, reserve for urgent medical emergency;
i , MR venography (MRV) should also be performed;
j , if MR imaging not available, contraindicated or inconclusive;
k , to exclude intracranial pressure changes;
l , MR imaging preferable, depending on availability;
m , needs contrast;
n , useful for problem solving or if there is a strong suspicion of vascular disease;
o , US, neck (carotid duplex) rating of 3;
p , x-ray skull rating of 4;
q , CT, head, with contrast rating of 3.
