European Journal of Cardiovascular Medicine

A headache is one of the most prevalent conditions that individuals encounter frequently. Approximately 90% of individuals experience a headache at least once every year, while around 40% suffer from a severe headache at least once annually.¹ It represents 4% of all hospital visits and is estimated to result in a cost of $150 million in lost workdays in the United States each year. Patients often seek medical care for headaches for at least two main reasons. The intensity of the pain experienced by the patient, along with their concerns about the possibility of having a brain tumour or aneurysm, are both factors that affect their choice to seek medical assistance.

Headaches, a common medical issue, can arise from a multitude of factors. Primary headache disorders consist of migraine, cluster, and tension-type headaches. Secondary headaches tend to be more frequent in individuals who have a pre-existing condition, such as a tumour or aneurysm, while migraine, cluster, and tension-type headaches are the most prevalent forms of primary headache disorders.² The majority of patients who visit their doctors with headache complaints do not have any significant underlying health issues contributing to their symptoms.^3,4

Routine imaging procedures such as CT scans to identify possible underlying causes of headaches have come under scrutiny due to the relatively low incidence of secondary headaches in comparison to primary headaches. The main objective of a neuroimaging study is to assist in diagnosing serious, treatable conditions that negatively affect a patient's quality of life, enabling them to receive appropriate treatment. However, there are many other important factors to consider. Using neuroimaging can alleviate patients' fears about having a medical condition, helping them feel more assured about both their health and the care they are receiving. The requests made by patients for neuroimaging studies, or those made by their family members, are valid justifications for obtaining such studies for individuals experiencing headaches. ^3,4

Very few individuals referred for cranial computed tomography are doing so due to severe headaches. Headaches are the most prevalent concern among patients requiring a CT scan. When addressing individuals who report headaches, considerable emphasis is placed on diagnosing and managing any possible intracranial conditions. Their headaches may stem from intracranial or peripheral nervous system issues, including meningitis, tumours, or other abnormalities of the peripheral nervous system. Headaches can originate from either brain sinuses or nasal sinuses. As computed tomography (CT) scans become increasingly accessible, they are often utilized to exclude brain tumours and other serious neurological disorders in patients who present with headaches. The use of these scans is on the rise.

OBJECTIVES:

• to determine the effectiveness of CT brain scans in identifying the underlying causes of headaches.
• To evaluate the extra benefit of obtaining limited PNS pictures after evaluating the brain in individuals with headaches.

Study Design: A prospective hospital-based cross-sectional study.

Study area: Department of Radio Diagnosis, Karuna Medical College, Chittor, Palakkad, Kerala.

Study Period: 1 year.

Study population: This cross-sectional study was conducted on 75 patients, who were presented with complaints of head-aches. 

Sample size: The study consisted of 75 subjects.

Sampling method: Simple random technique.

Inclusion criteria:

All patients (males & females) aged <12 years with headache (acute or chronic) with or without other neurological signs & symptoms.

Exclusion Criteria:

1. Headache due to ophthalmic cause.
2. With an immediate history of trauma.
3. Known cases of brain tumors or SOL in the brain.
4. Pregnant women with headache.

Ethical consideration: Institutional Ethical Committee permission was obtained before the commencement of the study.

Study tools and Data collection procedure:

The patient was positioned supine for the CT scan of the brain and restricted PNS, with the scan plane parallel to the orbito-meatal plane and at an angle of 10- 25 degrees to Reid's line. When the restricted PNS sections were produced, the segment's plane was oriented toward Reid's line. Serial sections were created using cuts spanning 4 millimetres supratentorial, 2.5 millimetres in the posterior fossa, and 5 millimetres across the PNS. If iodinated contrast media with a mean volume of 25 cc was provided to selected individuals to do a contrast investigation of the brain.

Patients' full clinical histories were taken, including details such as the frequency and severity of headaches, their onset and progression, and any accompanying symptoms such as nausea, vomiting, sensitivity to light, difficulty focusing, red eyes, neurological impairments, runny noses, and fevers. Known extra-central nervous system (CNS) malignancies and systemic diseases including hypertension were considered.

A tabular form was used to document the results. The predictive output from imaging in patients with simple headaches, headaches with concomitant symptoms such as nausea, vomiting, vision pathologies, and headaches without related symptoms was then statistically analysed. Examining the diagnostic accuracy from imaging in patients with migraine, tension headache, and persistent daily headache, as well as in patients with established systemic disease, was also studied.

Statistical analysis:

In the present study, descriptive statistical analysis was done. Results for categorical measurements are reported in Number (%) whereas results for continuous measurements are reported as Mean ±SD(Min-Max). At a 5% level of significance, significance is evaluated.

Figure 1: 38/M with thrombus may be suspected when there is widespread acute headache and vomiting that shows hyperdense straight sinuses.

Figure 2: 78/ F patient with rapid hypertension and the worst headache the patient ever had both presenting signs of diffuse SAH.

Figure 3: 55/M patient with Prostatic cancer with diffuse headache & vomiting showing SOL in the left cerebellum

Figure 4: 60/Ma meningioma was found in a patient who presented with widespread headache and vomiting and with extra-axial signs of SOL.

Figure 5: An ependymoma was found in the brain of a female patient of age 84 who had had a progressive development of headache and vomiting. Imaging revealed an intra- axial solid- cystic pathology in the right frontal lobe.

Figure 6: 10/Ma patient who suffers from recurrent headaches and has been diagnosed with bilateral sphenoid sinusitis.

Figure 7: 17/M patient presenting with persistent, widespread headache and a nasal septum that is deviated to the left.

The subjects in this research consisted of seventy-five individuals who were undergoing a CT-brain study & who presented with 10 complaints of headache. Of these 75 individuals, only eight of these patients had a CECT, and the remaining 67 patients had a normal CT scan done. In each patient, a brief examination of the PNS was performed. Before including these patients in the study, a comprehensive clinical history was obtained from each of them. This history included information about the nature of the headache, its onset (whether it was sudden or insidious), its duration, & any associated symptoms such as nausea, vomiting, blurred vision, photophobia, fever, running nose, neurological deficits, or any systemic illness. Patients who had already been given a diagnosis of a refractory mistake of the eye were excluded from the trial. After undergoing a CECT scan, one of the patients was discovered to have meningitis; two people were diagnosed to have metastases; and eligible participants were discovered to have cerebral vein thrombosis.

The patients' ages ranged from 21 to 29, with the majority falling in the 21 to 35-year age bracket. 35 years of age was the average for all of the patients. (26 % ). The age bracket of 30 to 39 years old had the second highest patient count after the 40 to 49-year-old bracket (23.5 %). The youngest patient was 12 years old, & the oldest patient was 84 years old. The number of patients who were above the age of 70 represented the least proportion of the total patient population. Imaging revealed a significant pathology in the age range of 50 to 59 years old (20 %), which was followed by the age group of 60 to 69 years old (17.6%). Imaging findings were found to be at their lowest in the age range of those younger than 19 years old. These results were consistent with those of previous studies, which had shown that a growing age was highly connected with severe anomalies in the body.5,6

Within the scope of this investigation, it was discovered that females outnumbered males by a margin of 53.5 %. &Comparatively speaking, 46.5 % of the total population under study. There were a total of 22 people, which is equivalent to 11 % of the general population, who demonstrated an aberration in imaging that may be attributed to the problems that the patients were suffering. This information was gleaned through medical scans. Supplemental ancillary observations that could not be credited to the patients' illnesses were observed in six patients. These additional findings were observed in two patients who had diffuse cerebral atrophy, two patients who showed calcific granulomas, and two patients who had chronic lacunar infarcts. Imaging revealed significant pathologies in approximately 10 (9.3 %) of the female patients & 12 (12.9 %) of the male patients. When it came to determining the source of the headache through imaging, there was no discernible difference between the sexes.

From 9 days to 98 months, headaches lasted anywhere from 2 months to 6 months. 71 individuals (35.5 %) suffered headaches that lasted more than six months before going away for more than a month (25.5 %). Patients with headaches lasting less than a month had the most pathologies on imaging, with 15 out of 51 patients showing signs of pathology, while those with headaches lasting less than six months had the fewest pathologies. Evans RW et al.7 people who had just begun experiencing headaches were found to have severe anomalies, which was similar to the findings of our investigation. 6 (3%) of the 22 patients studied had a SOL in the brain (intra or extra-axial), 2 of them (1%) had AISs, 1 of them (0.5%) had a SAH, 4 (2%) had CVT, & 9 (4.5%) had sinusitis (pansinusitis is also included), according to the results of this study. The study by Sherf M et al.8 found a comparable prevalence of brain pathologies known as space-occupying pathologies.

Neuro-imaging was sent to 60.5 % of patients with a headache without any associated symptoms or neurological dysfunction, followed by headaches with vomiting (22 % ). A similar study by Sherf M et al. When the indications and outcomes of brain CT were assessed by primary care doctors, the researchers found that the findings were consistent.8

In the group of 200 patients who participated in the study, 11 patients- had migraine, 3 patients- had tension headaches, 38 patients- had chronic daily headaches, 8 patients due to sinusitis, 2 patients due to meningitis, & other instances, had headaches did not meet any of the diagnostic criteria, and these headaches are collectively referred to as others. Imaging revealed the presence of an AIS in the region of the right MCA in the case of a migraine sufferer who had come with a sudden & severe onset of headache. Sphenoid sinusitis was found in a patient who presented with recurrent daily headaches. Patients who suffered from tension headaches were examined, & no pathologies were found in any of them. Imaging revealed acute sinusitis in four of the eight patients who were clinically suspected of having sinusitis. The remainder of the group displayed abnormal behaviour in 16 out of the total 138 cases.

 In the main types of headaches, the diagnostic yield from imaging is minimal, which is consistent with the findings of a study that was carried out by Evans RW et al. In individuals who suffer from migraine, ischemic episodes are a known entity that should be suspected if there is a change in the character of the headache, with or without associated neurological pathologies. One of the patients with migraine in this study experienced an abrupt onset of a severe headache that was not associated with any neurological pathologies. The rate of anomaly detection in migraine sufferers was eight %, which was higher than the rate found in past investigations (0-3 %).9 A relatively small number of people who suffer from migraines were included in this study, which is why imaging was able to uncover pathologies at such a high rate.

Imaging findings were found to be normal in 178 cases, which accounts for 89 % of the research population. Significant pathologies were found in 22 cases (11 %). The diagnostic value of imaging was limited in patients who presented with just a headache, with a PPR (positive predictive ratio) of less than 1. There were a total of 200 patients in the study group. Of those, 168 patients experienced diffuse headaches, of which pathology was found in 16 (9.7 %), & 32 patients had focused headaches, of which pathology was found in 6 (16.7 %). On imaging, the majority of these individuals who complained of focused headaches developed sinusitis. The likelihood ratio quantifies the degree to which a particular result alters the overall probability of having the condition. 

Twenty-two patients had a headache accompanied by a visual aberration. CT scans of the brain showed significant pathologies in four patients, two of whom were diagnosed with AISs, one with metastases to the cerebellum, one with a cortical vein thrombosis, & the other with an anomaly in the cortical vein. On imaging, pathologies were found in two individuals who had headaches & nausea. On imaging, both of them had sinusitis, which was unable to explain the ailment's presence. A low likelihood ratio of pathologies on imaging in individuals with headache & nausea (positive likelihood ratio of 0.71) was found in research conducted by Mitchell et al.10

Systemic disease was found in 21 patients, with hypertension being present in the majority of these patients (15 patients). Five of these were found to have substantial pathologies (23.8 %). After presenting with a history of rapid onset of acute headache and rush of hypertension, one patient was diagnosed with SAH. Additionally, two known cases of Ca Cervix with posterior fossa secondaries; one known case of CML had subdural deposits; & one known case of RHD with heart valve replacement had multiple AISs. When compared to patients who do not have any risk factors or systemic illness, patients who have systemic illness have a positive likelihood ratio of 2.5 times higher of discovering a pathology on imaging than patients who do not have any of those risk factors.

In this particular investigation, there were two individuals who, according to imaging, had AISs. Both of these patients had a risk factor for ischemic insult to the brain. The first individual was diagnosed with rheumatic heart disease, & the second individual suffered from migraines. Both patients suddenly developed a terrible headache, which was accompanied by nausea & a blurring of their eyesight.

Thirteen of the 22 patients who had a pathology on imaging were found to have an intracranial pathology as the root cause of their headache, while nine patients had sinusitis as the root cause of their headache. Five of the nine patients diagnosed with sinusitis experienced a sudden onset of headache, which was accompanied by fever & runny nose. Two patients were diagnosed with bilateral maxillary sinusitis, two patients were diagnosed with bilateral maxillary & ethmoid sinusitis, one patient was diagnosed with bilateral sphenoid sinusitis, one patient was diagnosed with bilateral ethmoid & sphenoid sinusitis, one patient was diagnosed with right frontal sinusitis, one patient was diagnosed with frontal-ethmoid sinusitis, & one patient was diagnosed with pan sinusitis. The clinical evaluation revealed that the patient with sphenoid sinusitis suffered from recurrent headaches that came & went but did not reveal any symptoms consistent with sinusitis. Patients typically present with a persistent headache when they have sphenoid sinusitis, which is one of the types of sinusitis that is frequently clinically ignored. On a simple radiograph, the condition is frequently overlooked. Imaging is of critical importance in these patients to determine the source of the headaches. Cross-sectional imaging is the method of choice to identify sinus head-aches from other types of headaches since the majority of sinus headaches include clinical features that are suggestive of either intra-cranial or paranasal pathologies due to the intra-cranial source of headaches brought on by stressful conditions. According to the findings of this investigation, increasing the yield by acquiring a limited number of PNS sections in addition to the CT brain is possible. Other benefits of gaining limited PNS sections include the ability to distinguish cerebral headache causes from those associated with the PNS, as well as a reduction in the costs associated with dedicated CT PNS imaging. The yield of CT brain & restricted PNS imaging together was 22, which is an increase of 11 % points from what would have been obtained with CT brain imaging alone (6.5 %).9.

When assessing individuals with headaches, a CT scan of the brain serves as an effective screening tool that can either identify structural issues or eliminate them from consideration. The additional acquisition of limited PNS sections enhances the imaging yield, lowers the costs associated with dedicated PNS imaging, and aids in distinguishing between headaches originating in the PNS and those arising from other areas in the brain. Patients who experience severe headaches, those that onset suddenly, or headaches accompanied by symptoms such as vomiting, fever, a runny nose, or neurological deficits tend to have a higher diagnostic yield from CT scans.

1. Fauci AS, Braunwald E, Kasper, Hauser SL, Longo DL, Jameson JL, et al. Head-ache. In: Harrison Principles of Internal Medicine. 17th ed. New York: McGraw Hill; 2008. p. 95-106(vol 1).
2. Rasmussen BK, Jensen R, Schroll M et al. Epidemiology of Headache in a General Population - a Prevalence Study. J Clin Epidemiol. 1991; 44: 1147-57.
3. Sargent JD, Solbach P. Medical evaluation of migraineurs: Review of the Value of Laboratory and Radiologic Tests. Head-ache. 1983; 23(2): 62-5.
4. Becker LA, Green LA, Beaufait D et al. Use of CT Scans for the Investigation of Headache: A report from ASPN, Part 1. J Fam Pract. 1993; 37(2): 129-134.
5. Carrera GF, Gerson DE, Schnur J, McNeil BJ. Computed Tomography of the Brain in Patients with Headache or Temporal Lobe Epilepsy: Findings and Cost-effectiveness. J Comput Assist Tomogr. 1977;1(2):200-203.
6. Aygun D, Bildik F. Clinical Warning Criteria in Evaluation by Computed Tomography the Secondary Neurological Headaches in Adults. Eur J Neurol 2003; 10: 437–42.
7. Evans RW. Diagnostic Testing for the Evaluation of Headaches. Neurological Clinic 2009; 27: 393-415.
8. Sherf M et al. Evaluate the indications and results of referrals for brain computerized tomography (CT) by primary care physicians. Eur J Neurol. 2003; 33: 182-96.
9. Benjamin M, Jay HR, David B et al. Evidence-Based Guidelines in the Primary Care Setting: Neuro-imaging in Patients with Nonacute Head-ache. US Headache Consortium. P. 2-25.
10. Mitchell CS, Osborn RE, Grosskreutz SR. Computed Tomography in the Head-ache Patient: Is Routine Evaluation Necessary? Head-ache. 1993; 33(2): 82-86.
11. Jordan JE, Flanders AE. Headache and neuroimaging: why we continue to do it. AJNR Am J Neuroradiol. 2020; 41:1149–55.
12. Blume HK. Childhood headache: a brief review. Pediatr Ann. 2017;46:e155–65.
13. Headache Classification Committee of the International Headache Society (IHS). The International Classification of Headache Disorders, 3rd edition. Cephalalgia. 2018;38:1–211.
14. Behzadmehr R, Arefi S, Behzadmehr R. Brain imaging findings in children with headache. Acta Inf Med. 2018;26:51–3.