Standard Of Care Re: Migraine Imaging Circa 2000?

[1UP]

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I saw a 34 y/o white, female patient recently that was concerned about the potential for congenital aneurysms after hearing a sudden increase over the last two or three months in what appeared to describe autophonic cranial bruits. The patient had a 1st degree relative that died suddenly from what was reported to be an undetected aneurysm that spontaneously ruptured approx. 30 months ago. Patient has a history of migraines, diagnosed per exclusionem by a neurologist in 2000. Imaging done at that time was non-contrast CT and non-contrast MRI which were both apparently nominal. Actual records of the imaging and diagnosis have not been obtained as the patient lived in another state at that time and could not recall the name of the doctor that ordered the studies.

What I'm wondering is if non-contrast MRA was part of the standard of care when a non-contrast MRI was ordered to r/o potential causes of migraine back in 2000? If so, I'm really going to make a push to try and find those records since it would give us more to work from with regard to the CC.

 

[Head]

To my knowledge, there has never been a standard of care for neuroimaging and migraine. If a patient comes in with fairly typical symptoms of migraine (severe pain lasting hours to days, unilateral, +n/v, photophobia, worse with physical activity), neuroimaging is not indicated. If there are any abnormalities on neuro exam, or complicated features like hemiplegia or speech disturbance, MRI brain w/ and w/o contrast is indicated.

When patients come in with fairly typical migraine, but are highly concerned about an intracranial process such as tumor I typically perform an MRI. In my experience they will not be happy with your care and will harbor continual anxiety until the study is done even though it is low yield.

Your case is a bit different in that they feel they can actually hear bruits in their head and provide a family history of cerebral aneurysm. I would recommend you repeat the MRI, but do it w/ and w/o contrast. Include an MRA of the head to be sure there is no cerebral aneurysm. If the prior study didn't include contrast, you can be fairly certain they didn't do an MRA either.

 

[pinkes]

I would say go for MRA....
but if headache is because of aneurysm then triptan wont have much effect...so u can try triptan and still patient is having headache then go for MRA...

 

[1UP]

Excellent points all around. I'll get the ball rolling on the pre-authorization paperwork. As you mentioned, she isn't likely to let it go until she has the imaging studies done.

To my knowledge, there has never been a standard of care for neuroimaging and migraine. If a patient comes in with fairly typical symptoms of migraine (severe pain lasting hours to days, unilateral, +n/v, photophobia, worse with physical activity), neuroimaging is not indicated. If there are any abnormalities on neuro exam, or complicated features like hemiplegia or speech disturbance, MRI brain w/ and w/o contrast is indicated.

When patients come in with fairly typical migraine, but are highly concerned about an intracranial process such as tumor I typically perform an MRI. In my experience they will not be happy with your care and will harbor continual anxiety until the study is done even though it is low yield.

Your case is a bit different in that they feel they can actually hear bruits in their head and provide a family history of cerebral aneurysm. I would recommend you repeat the MRI, but do it w/ and w/o contrast. Include an MRA of the head to be sure there is no cerebral aneurysm. If the prior study didn't include contrast, you can be fairly certain they didn't do an MRA either.

 

[typhoonegator]

The auditory bruit should be taken very seriously, in my opinion. Dural AVFs can do this with little to no intracranial nidus visible on CT or MRI.

Can you hear a bruit over her mastoid or eyeball with your stethoscope? Insensitive but very specific for such a flow diversion.

With the first degree family history and the auditory bruit I think you probably need to pursue vascular imaging to exonerate such a cause. CTA or MRA would be a good first move. The MRA can be GAD-enhanced or time-of-flight. Make sure a venous phase is represented if you do TOF.

 

[Mattchiavelli]

Imaging done at that time was non-contrast CT and non-contrast MRI which were both apparently nominal. Actual records of the imaging and diagnosis have not been obtained as the patient lived in another state at that time and could not recall the name of the doctor that ordered the studies.

Is this not the bane of the practicing neurologist?

 

[soulofmpatel]

aneurysms don't cause autophonic cranial bruits generally speaking to my knowledge. I'd be interested to hear the description of the noise disturbance. Is it more a pulsatile tinnitis that could suggest a carotid-cavernous sinus fistula? It sounds like you're going to have to get vascular imaging one way or the other.

I agree with others who say that it's unlikely that an MRA has been done previously.

Has anyone published statistics on MRI yield in patient's with headache meeting the criteria for a migraine?

 

[AlternateSome1]

IIH should be considered with her worsening headaches and possible pulsatile tinnitus.