MRA Head and Neck is NOT Indicated
In a teenage girl with headache and dizziness but a normal neurological examination, MRA of the head and neck is not recommended and should not be performed. 1
Evidence-Based Reasoning
The ACR Appropriateness Criteria for pediatric headache explicitly states there is no role for MRA in patients with primary headache and no concerning findings on clinical or physical examination 1. This guideline directly addresses your clinical scenario.
Key Decision Points
For the headache component:
- In children with primary headaches (migraine, tension-type) and normal neurologic examination, neuroimaging rarely contributes to diagnosis or management 1
- Studies show that despite imaging 324 children with headache, <1% had relevant findings to explain symptoms 1
- The yield of brain imaging is not contributory to diagnostic or therapeutic approach when examination is normal 1
For the dizziness component:
- The 2024 ACR dizziness guidelines specify that in nonspecific dizziness without vertigo, ataxia, or other neurologic deficits, usually no imaging is indicated due to low diagnostic yield 2
- MRA would only be appropriate if there were signs of vertebrobasilar insufficiency with brainstem neurologic deficits, which is not your scenario 2
When MRA Would Be Appropriate
MRA of head and neck becomes indicated only when specific "red flags" are present:
- Acute persistent vertigo with abnormal neurologic examination suggesting central vertigo 2
- Chronic recurrent vertigo with brainstem neurologic deficits suggesting vertebrobasilar insufficiency 2
- Evidence of stroke or hemorrhage on initial imaging 1
- Strong concern for arterial dissection 1
Common Pitfall to Avoid
Do not confuse migraine with cranial autonomic symptoms (rhinorrhea, nasal congestion) for "sinus headache" requiring imaging—approximately 62% of pediatric migraineurs have these symptoms from trigeminal-autonomic reflex activation 1. This can lead to unnecessary imaging.
What to Do Instead
If imaging is truly needed despite normal examination (high clinical suspicion, atypical features), MRI head without contrast would be the appropriate first-line study—not MRA 2, 1. However, even standard MRI is rarely contributory when the neurologic examination is completely normal 3.
The evidence consistently shows that important vascular and neoplastic findings are rare (0.1-2.0%) in patients with headache and normal neurologic examination 3, making routine vascular imaging with MRA unjustified in this population.