Should a Magnetic Resonance Imaging (MRI) of the head be performed with or without contrast for a headache?

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Last updated: March 21, 2025 • View editorial policy

From the Guidelines

For the initial evaluation of a headache, an MRI of the head without contrast is usually the appropriate first step, unless specific clinical features suggest the need for contrast, as indicated by the American College of Radiology criteria 1. When considering the use of MRI for headache evaluation, it's crucial to differentiate between primary and secondary headaches, as well as to identify any red flags that may necessitate a contrast-enhanced study.

  • Primary headaches, such as migraines or tension headaches without concerning features, typically do not require imaging with contrast initially.
  • Secondary headaches, which are caused by an underlying condition, may require imaging with contrast if the initial non-contrast study is abnormal, as suggested by the acr appropriateness criteria 1. Key factors influencing the decision to use contrast include:
  • The presence of red flags such as sudden severe headache (thunderclap headache), neurological deficits, seizures, or signs suggesting infection, inflammation, or cancer.
  • The clinical presentation and specific symptoms of the patient, which guide the determination of the appropriate MRI protocol by the radiologist and ordering physician. It's also important to consider the potential risks associated with contrast agents, including allergic reactions and contraindications in patients with certain kidney problems, as noted in the context of MRI studies 1. Given the recommendations from the American College of Radiology 1, the approach to using MRI with or without contrast for headache evaluation should prioritize the clinical context and suspected underlying cause, reserving contrast-enhanced imaging for cases where it is likely to provide additional diagnostic value.

From the FDA Drug Label

Gadoteridol was evaluated in two multicenter trials of 310 evaluable patients suspected of having neurological pathology. After the administration of gadoteridol 0.1 mmol/kg IV, the results were similar to those described below [see Clinical Studies ( 14. 2)] . In another multicenter study of 49 evaluable adult patients with known intracranial tumor with high suspicion of having cerebral metastases, two doses of gadoteridol were administered. First Gadoteridol Injection 0.1 mmol/kg was injected followed 30 minutes later with 0.2 mmol/kg. In comparison to the 0.1 mmol/kg dose alone, the addition of the 0. 2 mmol/kg dose improved visualization in 67% and improved border definition in 56% of patients. In comparison to non-contrast MRI, the number of lesions after 0.1 mmol/kg increased in 34% of patients. After gadoteridol 0. 2 mmol/kg, this increased to 44%.

Key Points:

  • The use of gadoteridol (a contrast agent) with MRI improved visualization and border definition in patients with suspected neurological pathology.
  • The addition of a second dose of gadoteridol (0.2 mmol/kg) after an initial dose (0.1 mmol/kg) improved visualization in 67% of patients and border definition in 56% of patients.
  • Compared to non-contrast MRI, the use of gadoteridol increased the number of lesions detected in 34% to 44% of patients.

Answer: For a headache, an MRI of the head with contrast may be performed to improve visualization and detection of lesions, as it has been shown to provide additional diagnostic information in patients with suspected neurological pathology 2.

From the Research

MRI with or without Contrast for Headache

  • The decision to perform a Magnetic Resonance Imaging (MRI) of the head with or without contrast for a headache depends on various factors, including the pretest probability, prevalence of diseases, sensitivity of imaging, and implications for treatment 3.
  • For the first presentation of a headache or a change in headache pattern, if the characteristics do not perfectly fit a primary headache type, imaging may be indicated according to the ICHD-2 criteria to exclude a secondary cause before a primary headache is diagnosed 3.
  • In headache patients without focal neurologic examination abnormalities, the yield of neuroimaging for significant intracranial findings is generally low 3, 4.
  • However, specific subgroups of headache patients and headache presentations can have much higher rates of significant intracranial abnormalities 3, 5.
  • The use of contrast in MRI for headache diagnosis is not explicitly mentioned in the provided studies, but it is generally used to enhance the visibility of certain structures or lesions in the brain.
  • A study on the use of MRI in chronic headache found that 52% of patients had abnormal MRI findings, but the difference between normal and abnormal findings was not significant 4.
  • The most common neoplastic and non-neoplastic abnormalities found in this study were pituitary macroadenoma (4%) and sinusitis (21.3%) respectively 4.
  • Another study compared diagnostic strategies for subarachnoid hemorrhage, including computed tomography followed by lumbar puncture, magnetic resonance imaging with magnetic resonance angiography, and computed tomography with computed tomography angiography 6.
  • The study found that each of these strategies has advantages and disadvantages, and the choice of protocol depends on patient factors, presentation factors, and institutional factors 6.

References

Guideline

Guideline Directed Topic Overview

Dr.Oracle Medical Advisory Board & Editors, 2025

Research

Imaging in the evaluation of headache.

The Medical clinics of North America, 2013

Research

Prevalence of herniation and intracranial shift on cranial tomography in patients with subarachnoid hemorrhage and a normal neurologic examination.

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, 2010

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.