Quality statement 3: Imaging

Quality statement

People with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.

Rationale

Referral for imaging solely for reassurance is most common in people diagnosed with tension-type headache and migraine. Therefore, the potential to reduce inappropriate referrals is greatest for these headache types. When healthcare professionals are confident about the diagnosis and classification of tension-type headache or migraine, imaging provides no more information and can lead to delays in diagnosis and treatment, and unnecessary anxiety for people.

Quality measures

Structure

Evidence of local arrangements to ensure that people with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.

Data source: Local data collection.

Process

Proportion of people with a tension-type headache or migraine who are referred for imaging.

Numerator – the number of people in the denominator referred for imaging.

Denominator – the number of people with tension-type headache or migraine.

Data source: Local data collection.

Outcome

Rate of positive findings of cause of headache on imaging.

Data source: Local data collection.

What the quality statement means for service providers, healthcare practitioners and commissioners

Service providers ensure that systems are in place so that people with tension-type headache or migraine are not referred for imaging if they do not have signs or symptoms of secondary headache.

Healthcare practitioners do not refer people for imaging if they have tension-type headache or migraine and no signs or symptoms of secondary headache.

Commissioners ensure that they commission services that do not refer people for imaging if they have tension-type headache or migraine and no signs or symptoms of secondary headache.

What the quality statement means for patients, service users and carers

People with tension-type headache or migraine are not referred for a brain scan if they do not have signs or symptoms of other conditions known to cause headaches.

Source guidance

  • Headaches (NICE clinical guideline 150), recommendations 1.3.3 (key priority for implementation), 1.1.1 and 1.1.2.

Definitions of terms used in this quality statement

Signs and symptoms of secondary headache are listed in NICE clinical guideline 150 as:

  • worsening headache with fever

  • sudden-onset headache reaching maximum intensity within 5 minutes

  • new-onset neurological defect

  • new-onset cognitive dysfunction

  • change in personality

  • impaired level of consciousness

  • recent (typically within the past 3 months) head trauma

  • headache triggered by cough, valsalva (trying to breathe out with nose and mouth blocked) or sneeze

  • headache triggered by exercise

  • orthostatic headache (headaches that change with posture)

  • symptoms suggestive of giant cell arteritis

  • symptoms and signs of acute narrow-angle glaucoma

  • a substantial change in characteristics of their headache.

NICE clinical guideline 150 also states criteria for which further investigations and/or referral may be considered for people who present with new-onset headache. These are:

  • compromised immunity, caused, for example, by HIV or immunosuppressive drugs

  • age under 20 years and a history of malignancy

  • a history of malignancy known to metastasise to the brain

  • vomiting without other obvious cause (for example a migraine attack).

Imaging includes CT, MRI or MRI variants.

Equality and diversity considerations

Some people may be anxious about not being referred for imaging and may need reassurance. Reassurance should take into account the needs of the individual, particularly any cultural needs, physical, sensory or learning disabilities, and of people who do not speak or read English. People should have access to an interpreter or advocate if needed.