Douglas Annette C, Wippold Franz J, Broderick Daniel F, Aiken Ashley H, Amin-Hanjani Sepideh, Brown Douglas C, Corey Amanda S, Germano Isabelle M, Hadley James A, Jagadeesan Bharathi D, Jurgens Jennifer S, Kennedy Tabassum A, Mechtler Laszlo L, Patel Nandini D, Zipfel Gregory J
Indiana University Hospital, Indianapolis, Indiana.
Mallinckrodt Institute of Radiology, Saint Louis, Missouri.
J Am Coll Radiol. 2014 Jul;11(7):657-67. doi: 10.1016/j.jacr.2014.03.024. Epub 2014 Jun 3.
Most patients presenting with uncomplicated, nontraumatic, primary headache do not require imaging. When history, physical, or neurologic examination elicits "red flags" or critical features of the headache, then further investigation with imaging may be warranted to exclude a secondary cause. Imaging procedures may be diagnostically useful for patients with headaches that are: associated with trauma; new, worse, or abrupt onset; thunderclap; radiating to the neck; due to trigeminal autonomic cephalgia; persistent and positional; and temporal in older individuals. Pregnant patients, immunocompromised individuals, cancer patients, and patients with papilledema or systemic illnesses, including hypercoagulable disorders may benefit from imaging. Unlike most headaches, those associated with cough, exertion, or sexual activity usually require neuroimaging with MRI of the brain with and without contrast to exclude potentially underlying pathology before a primary headache syndrome is diagnosed. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well-established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances in which evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.
大多数表现为无并发症、非创伤性原发性头痛的患者不需要进行影像学检查。当病史、体格检查或神经系统检查发现“红旗征”或头痛的关键特征时，则可能需要进一步进行影像学检查以排除继发性病因。影像学检查对以下头痛患者可能具有诊断价值：与创伤相关的头痛；新发、加重或突然发作的头痛；霹雳样头痛；放射至颈部的头痛；由三叉自主神经性头痛引起的头痛；持续性和体位性头痛；以及老年患者的颞部头痛。孕妇、免疫功能低下者、癌症患者以及患有视乳头水肿或全身性疾病（包括高凝性疾病）的患者可能从影像学检查中获益。与大多数头痛不同，那些与咳嗽、用力或性活动相关的头痛通常需要进行脑部MRI检查（有无对比剂），以排除潜在的基础病变，然后再诊断原发性头痛综合征。美国放射学会适宜性标准是针对特定临床情况的循证指南，由多学科专家小组每两年进行一次审查。指南的制定和审查包括对同行评审期刊上的当前医学文献进行广泛分析，并应用成熟的共识方法（改良德尔菲法）由专家小组对影像学检查和治疗程序的适宜性进行评分。在缺乏证据或证据不明确的情况下，可采用专家意见来推荐影像学检查或治疗。
