Is noncontrast head CT the right choice for patients with severe headaches?

Noncontrast head CT (NCCN) for patients with severe headaches provides little value when no other obvious "red flags" are present, according to a new study published in the Journal of the American College of Radiology.

The American College of Radiology (ACR) Appropriateness Criteria recommends utilizing NCCN for patients suffering a "worst headache of life" (WHOL) or "thunderclap headache" (TCH), but is that necessary? The researchers weren't convinced. 

“The hypothesis was that there would be little utility in performing emergency department (ED) NCCT scans in migraineurs without other red flags, even if they had WHOL or TCH,” wrote lead author David M. Yousem, MD, MBA, of Johns Hopkins Medical Institutions in Baltimore, Maryland.

Yousem and colleagues retrospectively studied NCCT scans taken in the ED of all established migraine patients who reported WHOL or TCH over a five-year period. Patients without known intracranial pathology, cancer, immunocompromising disease or recent head trauma were used as the main study group. Patients with any of those factors were included as the comparison group. 

The researchers graded the scans as normal (1), minor unimportant findings (2), findings requiring intervention or follow-up (3) or critical (4).

A total of 224 patients with WHOL or and TCH were studied. In the main study group—patients without those red flags—no patients had critical findings. Less than 1 percent had a grade 3 finding. The researchers also saw no cases of subarachnoid hemorrhage. 

The comparison group saw that 6.5 percent of patients had grade 4 findings and 3.3 percent had a grade 3 finding.

The researchers noted that the value of repetitive scanning of those with migraines who exhibit WHOL or TCH “is limited” unless they have established intracranial pathology, cancer, or recent head trauma.

“Given the low yield of NCCT, one must reconsider whether the ACR Appropriateness Criteria recommendation to scan patients with the 'red flag' of variant 3, WHOL or TCH, should pertain to the chronic migraine patient population,” they concluded.