Carl Cincinnato

Today we’re going to talk about a number of different diagnostic tests and how they apply to people who have various diagnoses. You never really know when you’re at the doctor’s office if they say “Well you need this,” or, for example, if you’re reading something, people might say you might need a brain scan. Getting the right tests is an important part of our diagnosis, but often they are simply not required. Sometimes there may be one or more tests that are really important to your diagnosis.

To help us find out when to test, and when not to, we had a conversation with Professor Dimos-Dimitrios Mitsikostas. Professor Mitsikostas is a specialist in headache, a neurologist, and council member of the European Headache Federation, and president of the Greek Headache Society.

What kinds of test are important for people with migraine to have?

Dr. Mitsikostas: “None. As you may know, the classification we do have right now, the International Classification for Headache Disorders, is just taken from the history and physical examination. So, if the patient tells the story in the right way and fulfills the criteria for migraine, then we do have a migraine. The only thing that the physician has to do and to perform, in a very detailed way, is to make a physical and neurological examination. When this examination is negative, really you don’t have to perform any test because we don’t have any real biomarker for migraine. Having said that, let’s move to see what happens in everyday clinical practice, because patients sometimes do request to have a scan just to feel comfortable that nothing else is moving within their head. In real life, and personally, I always consider the patient’s needs. So in case I cannot convince him or her, then I offer an MRI. There are not any dangers in repeating MRI scans, but it’s very expensive and, as physicians, we also have to take into account the cost of the tests we are ordering because we want to save that money for those who really need it.

So let’s talk about headache and not about migraine because, if you have the diagnosis of migraine, nothing’s required unless you have some very particular subtypes and very rare subtypes of migraine, like migraine with prolonged aura, or hemiplegic migraine, or brain stem aura, or some very particular subtypes of migraine; then it is required to have not only a brain scan but other tests, as well. And this is always the case when we are talking about headaches. We need some tests not to diagnose the headache subtype but to exclude other brain disorders that may mimic that particular headache.

So, if headache is an extremely acute, thunderclap headache, then the physician has the right to start considering whether a brain scan is useful or not. So that’s case one. Case two is you have recent headaches that started a few months ago, and they are aggravated within weeks or months. You may start thinking whether a brain scan would be helpful or not. And the third red flag is this one: you have a patient who is, or she is, complaining of chronic headaches, and suddenly those headaches change features, change characteristics. So those three cases are the cases that the European Headache Federation suggests to physicians to take into account to start considering whether a test should be helpful to exclude any secondary headache that might mimic a primary one.”

If a person with migraine has aura symptoms, does that change the need for testing?

Dr. Mitsikostas: “That’s one of our recommendations in the European Headache Federation; that if you have persistent migraine aura, you have to perform an MRI scan. And if those auras are not typical, you have to perform, as a physician, an MRI. So there are particular, as I said before, particular migraine subtypes where a physician has to –must –perform an MRI.”

Is a test for PFO (patent foramen ovale) valve closure* necessary?

Dr. Mitsikostas: “That was a long story still open for some people. We had evidence a decade ago that PFO was open for those that were suffering from migraine with aura. And we still have that. Most of us, we believe that there is a vascular component in migraine pathogenesis and that has to be related somehow with endothelium changes in arteries. That might cause both PFO and migraine with aura. In any case, there were at least three trials in which we closed PFO, and we observed whatever migraines go on at all. And we saw no real effect. So there is no recommendation for those that are suffering from migraine with aura to look for PFO because closure of PFO does not help. And, on the other hand, the open PFO, if you don’t have other symptoms surfacing, you don’t have to touch it –I mean, it’s something that you may live with it.”

*PFOs … occur after birth when the foramen ovale fails to close. The foramen ovale is a hole in the wall between the left and right atria of every human fetus. This hole allows blood to bypass the fetal lungs, which cannot work until they are exposed to air. When a newborn enters the world and takes its first breath, the foramen ovale closes, and within a few months it has sealed completely in about 75 percent of us. When it remains open, it is called a patent foramen ovale, patent meaning open. For the vast majority of the millions of people with a PFO, it is not a problem, even though blood is leaking from the right atrium to the left. Problems can arise when that blood contains a blood clot.”

Key Questions:

How important are patient history and physical examination in diagnosing migraine?
Do people with migraine need to worry about white-matter lesions in brain scans?
Is there any danger in having repeated brain scans?
What tests are needed for a person with cluster migraine?
What types of tests should be administered for rare subtypes of migraine, like hemiplegic migraine, migraine with prolonged aura or hypnic headache?
What does CFS (cerebral spinal fluid) pressure have to do with migraine?
What tests are needed for people with primary exercise headache or headache related with sexual activity?
Why would a person with migraine need an EEG?

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Posted in: Migraine Education

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