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  1. Cathie Sudlow
  1. Correspondence to:
 Dr Cathie Sudlow, Department of Clinical Neurosciences, University of Edinburgh, Western General Hospital, Crewe Road, Edinburgh EH4 2XU, UK;

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The US Headache Consortium is a group of 14 US doctors (mainly academic neurologists) who aim to “develop scientifically sound, clinically relevant practice guidelines on chronic headache in the primary care setting”.1 The consortium has produced several sets of guidelines, endorsed by the American Academy of Neurology and several other relevant US medical academic societies. These include the guidelines on neuroimaging of non-acute headache patients.1 As far as I am aware, these are the only available guidelines addressing this issue. Non-acute (or chronic) headache is defined as all headache syndromes lasting for at least four weeks, and the “primary care setting” in the USA refers to patients seen in an outpatient setting by a family doctor, a general physician or a specialist.


The guidelines begin by pointing out that headache is very common and that the majority of headaches (tension type and migraine) are benign. There is, therefore, a very low probability of identifying a causative lesion on a brain scan of an unselected outpatient presenting with headache, so that neuroimaging is highly unlikely to be a sensible “routine” investigation among outpatients with headache. In practice, a brain scan may be requested for one or more of several different reasons:

  1. the physician suspects a causative structural lesion whose identification would alter the clinical management of the patient

  2. the scan is expected to be normal and so reassure the patient, their relatives and/or the doctor

  3. the patient, relatives or referring doctor (if there is one) specifically request a scan

  4. the physician wants to avoid any possibility of a lawsuit based on failure to diagnose a lesion, even if it is an incidental finding and unrelated to the headache.

Neuroimaging to identify a suspected structural lesion

The guidelines focus mainly on the use of neuroimaging to identify a suspected structural …

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