From the Guidelines
For evaluation of migraines, a standard MRI of the brain with and without contrast is typically recommended only when a secondary headache disorder is suspected, as stated in the 2021 study 1. This approach is based on the principle of minimizing unnecessary testing while ensuring that potential underlying conditions are identified and addressed. The use of neuroimaging in migraine evaluation should be guided by the presence of atypical features, neurological symptoms, or other "red flags" that suggest a possible secondary cause for the headaches, as outlined in the guidelines from the U.S. Headache Consortium 1. Key points to consider in the evaluation of migraines include:
- Recording a detailed medical history
- Applying diagnostic criteria for migraine
- Considering differential diagnoses
- Performing a thorough physical and neurologic examination to exclude other causes
- Using neuroimaging judiciously, based on the suspicion of a secondary headache disorder 1. It's also important to note that most migraine patients have normal MRI results, as migraines are primarily a clinical diagnosis based on symptoms and medical history rather than imaging findings. The preference for MRI over CT scans in migraine evaluation is due to its better soft tissue detail and lack of radiation, making it a safer choice for patients who require imaging 1. However, the decision to perform an MRI should always be made on a case-by-case basis, taking into account the individual patient's symptoms, medical history, and risk factors for secondary headache disorders.
From the Research
MRI Evaluation for Migraines
- The type of MRI necessary for the evaluation of migraines is not explicitly stated in the provided studies, but functional MRI (fMRI) and diffusion tensor imaging (DTI) have been used to investigate migraine pathophysiology 2, 3.
- fMRI has been used to study changes in functional connectivity and regional activation in pain-related networks in migraineurs, while DTI has been used to examine white matter microstructural changes 2.
- A systematic review of fMRI studies in migraine found that repeatedly emerging structures of interest included the insula, brainstem, limbic system, hypothalamus, thalamus, and functional networks 3.
- Another study found that brain MRI can reveal incidental findings in patients with migraine, including clinically significant findings that may require intervention, particularly in patients over 40 years old 4.
Key Findings
- Changes in functional connectivity and regional activation in pain-related networks have been observed in migraineurs using fMRI 2, 3.
- White matter microstructural changes have been observed in major cortical white matter tracts extending to the brainstem and cerebellum in chronic migraineurs 2.
- Brain MRI can reveal incidental findings in patients with migraine, including clinically significant findings that may require intervention 4.