Is a CT (computed tomography) scan necessary for an adult patient with a known history of migraines?

CT Scan for Adult Migraine Patients

A CT scan is not necessary for an adult patient with a known history of migraines and a normal neurological examination, as the yield of significant abnormalities (0.2%) is no higher than in asymptomatic individuals (0.4%). 1, 2

When Imaging Is NOT Warranted

• Patients with established migraine diagnosis and completely normal neurological examination do not require neuroimaging, as only 2 out of 1,086 migraine patients (0.2%) had serious abnormalities detected on brain imaging—a rate identical to asymptomatic volunteers. 1, 3

• The American Academy of Family Physicians explicitly states that neuroimaging (either MRI or CT) is not usually warranted in migraine patients with normal neurological findings (Grade B recommendation). 2

• Testing should be avoided if it will not change clinical management or if the patient is not significantly more likely than the general population to have a significant abnormality. 2, 4

• False positive findings are more likely than true positives in low-risk patients, potentially triggering harmful cascades of unnecessary procedures. 3

Red Flags That DO Require Imaging

Neuroimaging should be performed immediately if ANY of the following features are present:

• Abnormal neurological examination findings (focal deficits, papilledema, altered mental status)—this is the single most important indicator, as 94% of patients with brain tumors causing headache have abnormal neurological findings at diagnosis. 2, 4

• Thunderclap or "worst headache of life" presentation—though one study found zero cases of subarachnoid hemorrhage in known migraineurs without other risk factors, this remains a critical red flag requiring immediate CT. 4, 5

• Headache awakening patient from sleep—this pattern suggests increased intracranial pressure and warrants imaging. 3, 4

• Progressive worsening over weeks—a headache that steadily worsens over 3+ weeks justifies imaging even with normal examination, as this pattern suggests space-occupying lesions or increased intracranial pressure. 3, 2

• Headache worsened by Valsalva maneuver (coughing, straining, bending)—this suggests increased intracranial pressure. 4, 6

• New-onset headache in patients over age 50—this raises suspicion for temporal arteritis, mass lesions, or other secondary causes. 4, 6

• Marked change in previously stable headache pattern—a significant deviation from the patient's typical migraine presentation requires investigation. 4

• Recent head or neck trauma with persistent headache. 4, 6

Choosing Between CT and MRI

If imaging is indicated, MRI brain without contrast is the preferred modality for elective evaluation of headache patients, as it provides superior detection of soft tissue abnormalities, inflammatory processes, demyelinating diseases, and small infarcts. 3, 2

However, non-contrast CT is appropriate when:

• Acute subarachnoid hemorrhage is suspected (CT has 98% sensitivity for acute blood). 2

• Immediate imaging is needed in emergency settings (CT is faster and more readily available). 2

• The patient has red flags requiring urgent evaluation for hemorrhage, hydrocephalus, or large masses. 2

Critical Pitfalls to Avoid

• Do not order imaging "for reassurance" in patients with typical migraine features and normal examination—this leads to overutilization and potential harm from false positives. 4

• Do not misdiagnose "sinus headache"—approximately 62% of pediatric migraineurs have cranial autonomic symptoms (rhinorrhea, lacrimation) that mimic sinus disease; this pattern does not warrant imaging. 1, 2

• Do not skip the neurological examination—the presence or absence of abnormal findings is the primary determinant of imaging necessity. 2

• Do not use CT when MRI is more appropriate—CT misses the majority of structural lesions responsible for secondary headache in non-emergent settings. 2