American Headache Society

View all recommendations from this society

Released November 21, 2013

Don’t perform computed tomography (CT) imaging for headache when magnetic resonance imaging (MRI) is available, except in emergency settings.

When neuroimaging for headache is indicated, MRI is preferred over CT, except in emergency settings when hemorrhage, acute stroke or head trauma are suspected. MRI is more sensitive than CT for the detection of neoplasm, vascular disease, posterior fossa and cervicomedullary lesions and high and low intracranial pressure disorders. CT of the head is associated with substantial radiation exposure which may elevate the risk of later cancers, while there are no known biologic risks from MRI.

These items are provided solely for informational purposes and are not intended as a substitute for consultation with a medical professional. Patients with any specific questions about the items on this list or their individual situation should consult their physician.

How The List Was Created

The American Headache Society (AHS) Board of Directors approved the creation of a task force to lead work on the Choosing Wisely® campaign. The task force consisted of: Elizabeth Loder, MD, MPH, (AHS President), Stephen Silberstein, MD, (Chair of the AHS Guidelines and Position Paper Committee), Randolph Evans, MD, Benjamin Frishberg, MD, Scott Litin, MD, Donald Dworek, MD, Josif Stakic, MD, and Jessica Ailani, MD.

The list was developed in consultation with AHS members, who received an electronic survey informing them of the project and asking them to recommend items to be considered for the list. The task force reviewed a list of 11 candidate topics that had been developed from the over 100 suggestions received from AHS members.

The task force met twice by conference call to review the suggestions and choose items for further development, and then communicated electronically during the development and approval process. Final items were selected based on commonly encountered situations in headache medicine associated with poor patient outcomes, low-value care or misuse or overuse of resources. The five recommendations were then approved by the AHS Executive Committee and Board of Directors.

The AHS disclosure and conflict of interest policy can be found at:


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Evans R. Diagnostic testing for migraine and other primary headaches. Neurol Clin. 2009 May;27(2):393–414.

Semelka RC, Armao DM, Elias J Jr, Huda W. Imaging strategies to reduce the risk of radiation in CT studies, including selective substitution with MRI. J Magn Reson Imaging. 2007;25(5):900–09.

Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation exposure. N Engl J Med. 2007;357(22):2277–84.