Does a patient with neck pain, vision changes, and migraines require an MRI of the brain with or without contrast?

MRI Brain Without Contrast is Appropriate for This Clinical Presentation

For a patient presenting with neck pain, vision changes, and migraines, start with MRI brain WITHOUT contrast, as contrast administration provides minimal additional diagnostic yield for these symptoms and exposes the patient to unnecessary risks including nephrogenic systemic fibrosis and gadolinium retention. 1, 2

Primary Imaging Recommendation

• MRI cervical spine without IV contrast is the preferred initial imaging modality for patients with neck pain and neurological symptoms (including vision changes), as it provides superior soft tissue contrast for evaluating nerve root impingement and has the highest diagnostic accuracy 1
• MRI brain without contrast should be obtained if intracranial pathology is suspected, particularly given the vision changes and migraines in this patient 2, 3
• The combination of neck pain with vision changes raises concern for cervicogenic headache or cervical arterial pathology, which can be initially evaluated without contrast 4, 5

Why Contrast is NOT Indicated

• Routine contrast-enhanced brain MRI for headache evaluation has only a 2% yield for contrast-relevant findings, while noncontrast examinations demonstrate similar sensitivity for actionable intracranial pathology 2
• All intra- and extra-axial masses associated with parenchymal edema were detected without contrast in a blinded review study of 874 consecutive headache cases 2
• Contrast administration doubles the detection rate of incidental meningiomas but does not improve detection of clinically significant pathology causing headaches 2
• The American College of Radiology states there is insufficient evidence to support MRI with contrast for initial imaging of migraine-related symptoms 6

When Contrast WOULD Be Indicated

Add contrast (without and with IV contrast protocol) only if:

• Initial noncontrast MRI demonstrates a mass lesion requiring further characterization 4
• There is clinical suspicion for infection, inflammatory process, or demyelinating disease 4
• Known malignancy with new neurological symptoms 1
• Cranial neuropathy is identified on examination, suggesting skull base pathology 4

Specific Protocol Recommendations

For this patient, order:

• MRI brain without IV contrast including DWI, FLAIR, and gradient-echo sequences to evaluate for acute ischemia, white matter disease, and hemorrhage 6, 3
• MRI cervical spine without IV contrast to evaluate for cervicogenic causes of headache and vision disturbances 1, 5
• Consider adding MRA head and neck without IV contrast if there is concern for cervical arterial dissection given the combination of neck pain and vision changes 4, 6

Clinical Context for Vision Changes

• Visual symptoms are commonly reported by patients with neck pain, with 70% experiencing "need to concentrate to read" and 58.6% reporting "sensitivity to light" 7
• These visual disturbances may be related to eye movement control disturbances associated with neck pain rather than primary intracranial pathology 7
• The presence of vision changes does not automatically necessitate contrast administration unless specific "red flag" features are present 4, 5

Critical Safety Considerations

• Gadolinium-based contrast agents carry risks including nephrogenic systemic fibrosis in patients with impaired renal function and gadolinium retention in brain, bone, and other organs for months to years even in patients with normal renal function 8
• The clinical consequences of gadolinium retention remain unknown 8
• Contrast should only be used when the diagnostic information is essential and not available with noncontrast imaging 8

Common Pitfalls to Avoid

• Do not reflexively order contrast for all headache evaluations – this represents overutilization with minimal diagnostic benefit 2
• Do not delay imaging if "red flags" are present (prior neck surgery, suspected infection, intractable pain, systemic disease, abnormal labs) – these warrant immediate MRI evaluation 1, 5
• Do not assume a negative brain MRI rules out cervical spine pathology as the cause of headache radiating from the neck 5
• Recognize that white matter lesions on MRI are common in migraine patients (29.4% in patients under 40) but do not require contrast for detection 9