This is a retrospective chart review study examining the rate of neuroimaging performed for migraine and origin of referrals to specialized headache centers.

Headache is one of the most common and costly disorders in healthcare. A significant amount of the overall cost can be attributed to neuroimaging, which has a low yield of abnormalities in patients with typical headache patterns and a normal neurological examination. Despite this and multiple guidelines for headache care management, the percentage of patients receiving neuroimaging is increasing.

100 patients who received a referral to the headache center from March 2018-July 2018 were identified and the source of the referral (location and provider type) was recorded, along with any neuroimaging performed. 

85 women and 15 men were identified with age ranging from 17 to 68. 58% of patients had previous imaging ordered for headache, often by multiple different providers.  91% of imaging was normal, not completed, or with mild/incidental findings. Abnormal findings included atrophy, tonsillar ectopia, meningioma, hemangioma, and infarct. MRI alone was the most common type of imaging ordered (39%). 35% of patients had multiple forms ordered.  Clinic location (rural vs urban), provider title (MD, NP, DO, etc), and patient sex did not affect imaging rates. Average age was significantly lower in those who had imaging ordered (37.9) compared to those who did not (44.1) (p=0.016). Emergency medicine was the specialty that ordered the most imaging (followed closely by neurology), while family medicine ordered the least.

Neuroimaging is not considered necessary in patients with normal exam and typical features. 58% of patients diagnosed with migraine headache had neuroimaging prior to tertiary headache center referral (91% of which was normal). Increase in education targeting emergency medicine and neurology trainees may help decrease the rate of imaging ordered, which in turn might help mitigate expanding healthcare cost.