Pitfalls in Neuroimaging of Headache: A Case Report and Review of the Literature

Headache is a common symptom, with a lifetime prevalence of over 90% of the general population in the United Kingdom (UK). It accounts for 4.4% of consultations in primary care and 30% of neurology outpatient consultations. Neuroimaging is indicated in patients with red flag features for secondary headaches. The guidelines recommend CT or MRI scan to identify any intracranial pathology. We present a unique case where the initial noncontrast CT scan failed to identify a potential treatable cause for headache. A middle aged man presented with headache and underwent a CT scan without contrast enhancement. The scan was reported as normal. The headache persisted for years and the patient underwent a staging CT scan to investigate an oropharyngeal cancer. This repeat CT scan utilized contrast enhancement and revealed a meningioma. Along with other symptoms, headache is an established presenting complaint in patients with meningioma. The contrast enhanced CT brain proved superior to a nonenhanced CT scan in identifying the meningioma. In a patient with persistent headache where other causes are excluded and a scan is to be requested, perhaps contrast enhanced CT is a better option than a plain CT scan of brain. 1. Introduction Headache is a common symptom, with a lifetime prevalence of over 90% of the general population in the clinical practice [1]. Overall 1-year prevalence of headache in European adults is 51% [2]. It accounts for 4.4% of consultations in primary care and 30% of neurology outpatient consultations. Neuroimaging is indicated in select patients with headache. The guidelines suggest that either a CT or MRI scan can be done to identify any intracranial pathology. We report a unique case where the initial CT scan failed to identify a potentially treatable cause for headache. 2. Case Report A 74-year-old Caucasian male originally presented to the headache clinic with 1-year history of right sided headache affecting the frontotemporooccipital region. It was daily persistent headache with a pain intensity of 4/10. The nature of pain varied between dull ache with short lived shooting in the right retroorbital area once or twice a week with occasional photophobia. There was no nausea or visual dysfunction. Postural changes or valsalva did not aggravate the headache. The headache failed to settle with analgesics. There was a previous history of migraine in his teens which varied in frequency and severity. The last episode of migraine was experienced 10 years ago. There was a positive family history of migraine with both mother and sister undergoing