What is the next step in imaging for a patient with migraines who has completed a course of physical therapy?

Imaging After Physical Therapy for Migraine

In patients with migraine who have completed physical therapy and have a normal neurological examination, neuroimaging is not indicated and should not be performed. 1

Clinical Decision Framework

The decision to pursue imaging depends entirely on the presence or absence of red flags and neurological examination findings, not on the completion of physical therapy:

When Imaging is NOT Warranted

• Patients with typical migraine features and normal neurological examination should not undergo imaging, regardless of treatment history, as the yield of significant abnormalities is only 0.2% (2/1086 patients)—equivalent to the asymptomatic general population at 0.4%. 1, 2, 3

• Physical therapy completion does not change this recommendation, as neuroimaging serves only to exclude secondary causes suspected based on clinical red flags, not to evaluate treatment response. 1

• Patient-requested imaging in migraine with normal examination yields no higher detection rate than the general population (1% tumor prevalence vs. 1.2% in asymptomatic controls, p > .99). 4

When Imaging SHOULD Be Considered

Neuroimaging is indicated only when red flags emerge in the history or examination: 1

• Abnormal neurological examination findings (focal deficits, papilledema, impaired memory, altered consciousness) mandate immediate imaging. 1, 2

• Historical red flags that warrant imaging include:

  • Thunderclap headache (sudden, severe onset) 1
  • Headache awakening patient from sleep 1, 2, 3
  • Progressive worsening over weeks 1, 2, 3
  • Headache worsened by Valsalva maneuver 1, 3
  • New-onset headache after age 50 1, 5, 3
  • Unexplained fever or neck stiffness 1
  • Atypical aura features 1

Imaging Modality Selection (If Indicated)

MRI without contrast is the preferred modality when imaging is clinically warranted: 1, 5, 3

• MRI provides superior resolution without ionizing radiation and better detects structural lesions, inflammatory processes, and small infarcts compared to CT. 2, 5, 3

• CT should be reserved for emergency settings when acute hemorrhage or subarachnoid hemorrhage is suspected, or when MRI is unavailable or contraindicated. 5, 3

Critical Pitfalls to Avoid

• Do not order imaging simply because conservative treatment failed. Treatment response does not predict the presence of structural pathology in patients with normal examinations. 1

• Do not image for reassurance purposes alone. While patient anxiety is understandable, imaging without clinical indication exposes patients to unnecessary testing, potential incidental findings requiring further workup, and does not improve outcomes. 1, 4

• Beware of "sinus headache" misdiagnosis. Approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, nasal congestion) that mimic sinusitis—this does not warrant sinus imaging. 1, 3

Next Steps in Management

Instead of imaging, the appropriate next steps after physical therapy include:

• Optimize acute medication management with NSAIDs as first-line (ibuprofen, naproxen, diclofenac) or triptans as second-line therapy. 1

• Consider preventive therapy if migraine continues to impair quality of life on ≥2 days per month despite optimized acute treatment, including options such as beta-blockers, anticonvulsants, or CGRP monoclonal antibodies. 1

• Assess for medication-overuse headache if acute medications are used ≥10 days per month. 2