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## Complete Summary

#### GUIDELINE TITLE

Neurophysiological tests and neuroimaging procedures in non-acute
headache: guidelines and recommendations.

#### BIBLIOGRAPHIC SOURCE(S)

Sandrini G, Friberg L, Janig W, Jensen R, Russell D, Sanchez del Rio M,
Sand T, Schoenen J, van Buchem M, van Dijk JG. Neurophysiological tests
and neuroimaging procedures in non-acute headache: guidelines and
recommendations. Eur J Neurol 2004 Apr;11(4):217-24. \[43 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15061822)

#### GUIDELINE STATUS

This is the current release of the guideline.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

Non-acute headache

#### GUIDELINE CATEGORY

Diagnosis\
Evaluation\
Technology Assessment

#### CLINICAL SPECIALTY

Family Practice\
Internal Medicine\
Neurology\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To help physicians make appropriate choices regarding the use of
instrumental tests in non-acute headache patients

#### TARGET POPULATION

Patients presenting with non-acute headache

#### INTERVENTIONS AND PRACTICES CONSIDERED

**Neurophysiological Tests and Neuroimaging Procedures\***

1.  Routine electroencephalogram (EEG) with standard visual
    interpretation

2.  Quantitative EEG methods (frequency analysis with or without
    topographic mapping)

3.  Analysis of photic driving

4.  Evoked potentials

5.  Reflex responses

6.  Autonomic tests

7.  Clinical tests, pain pressure thresholds, and electromyography (EMG)
    (with special reference to tension-type headache)

8.  Neuroimaging (magnetic resonance imaging \[MRI\])

9.  Single photon emission computerized tomography (SPECT) and photon
    emission tomography (PET)

10. Transcranial Doppler examination

\*Note: See \"Major Recommendations\" field for context; some of these
tests and procedures are considered but not recommended because of their
limited utility in the clinical setting.

#### MAJOR OUTCOMES CONSIDERED

Usefulness, sensitivity, and specificity of tests and procedures for
diagnosis and evaluation of non-acute headache

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

The task force collected and selected evidence according to the European
Federation of Neurological Societies (EFNS) criteria (Hughes RAC, Barnes
MP, Baron J, Brainin M \[2001\]. Guidance for the preparation of
neurological management guidelines by EFNS scientific task forces. *Eur
J Neurol* 8:549-550).

Reviews of published clinical evidence (from 1988 to 2002) were
evaluated. Key literature references pre-dating the International
Headache Society (IHS) Classification (1988) were particularly carefully
examined as these studies applied different diagnostic criteria for
headache.

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Weighting According to a Rating Scheme (Scheme Given)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

**Evidence Classification Scheme for a Diagnostic Measure**

**Class I**: A prospective study in a broad spectrum of persons with the
suspected condition, using a \"gold standard\" for case definition,
where the test is applied in a blinded evaluation, and enabling the
assessment of appropriate tests of diagnostic accuracy

**Class II**: A prospective study of a narrow spectrum of persons with
the suspected condition, or a well-designed retrospective study of a
broad spectrum of persons with an established condition (by \"gold
standard\") compared to a broad spectrum of controls, where test is
applied in a blinded evaluation, and enabling the assessment of
appropriate tests of diagnostic accuracy

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls)

#### METHODS USED TO ANALYZE THE EVIDENCE

Systematic Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

The expert task force appointed by the Scientific Committee of the
European Federation of Neurological Societies (EFNS) prepared the
guidelines according to EFNS criteria (Hughes RAC, Barnes MP, Baron J,
Brainin M \[2001\]. Guidance for the preparation of neurological
management guidelines by EFNS scientific task forces. *Eur J Neurol*
8:549-550).

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

**Rating of Recommendations**

**Level A rating** (established as useful/predictive or not
useful/predictive) requires at least one convincing class I study or at
least two consistent, convincing class II studies.

**Level B rating** (established as probably useful/predictive or not
useful/predictive) requires at least one convincing class II study or
overwhelming class III evidence.

**Level C rating** (established as possibly useful/predictive or not
useful/predictive) requires at least two convincing class III studies.

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

The guidelines were validated according to the European Federation of
Neurological Societies (EFNS) criteria (Hughes RAC, Barnes MP, Baron J,
Brainin M \[2001\]. Guidance for the preparation of neurological
management guidelines by EFNS scientific task forces. *Eur J Neurol*
8:549-550).

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The levels of evidence (class I-IV) supporting the recommendations and
ratings of recommendations (A-C) are defined at the end of the \"Major
Recommendations\" field.

**Electroencephalogram (EEG)**

*Routine EEG with Standard Visual Interpretation*

Interictal EEG is not routinely indicated in the diagnostic evaluation
of headache patients. Interictal EEG is only indicated if the clinical
history suggests a possible diagnosis of epilepsy, e.g., in the case of
(i) unusually brief headache episodes; (ii) unusual aura symptoms (e.g.,
gastric/olfactory sensations, circular visual symptoms); (iii) headache
associated with unusually brief auras or aura-like phenomena; (iv)
headache associated with severe neurological deficits; and (v) other
risk factors for epilepsy. Ictal EEG is indicated during episodes
suggesting complicated aura and during auras associated with decreased
consciousness or confusion.

*Quantitative EEG Methods (Frequency Analysis with or without
Topographic Mapping)*

Current quantitative EEG methods are not routinely indicated in the
diagnostic evaluation of headache patients.

Quantitative frequency analysis of EEG must always be recorded with raw
EEG data and interpreted by a skilled physician in order to avoid
misinterpretation of technical artifacts, normal state fluctuations and
various physiological rhythms.

*Analysis of Photic Driving*

Photic driving may be increased in migraine and tension-type headache
(TTH) patient groups as compared with headache-free subjects. The
specificity of the method is not yet sufficiently documented.

There is not enough evidence to suggest that the photic driving methods
that are currently in use can reliably discriminate either between
migraine and nonmigraine primary headache patients or between primary
headache patients and headache-free subjects.

*This is a class II level of evidence and the grade of recommendation is
B.*

**Evoked Potentials (EPs)**

The literature data, often conflicting, failed to demonstrate the
usefulness of EPs as a diagnostic tool in migraine. Findings should
therefore be replicated before visually evoked potentials (VEPs) can be
recommended in the diagnosis of migraine (not enough data are available
for other types of headache). In conclusion, the Task Force does not
recommend the use of EPs in the diagnosis of headache disorders.

*This is a class II level of evidence, but the literature contains
contrasting data and the clinical significance of abnormalities is
poorly understood. The grade of recommendation is B.*

**Reflex Responses**

Most of the neurophysiological investigation techniques have only
limited usefulness in the diagnosis of headache. Further research in
large populations is needed in order to establish which
electrophysiological markers could be relevant in clinical practice.

*This is a class IV level of evidence for nociceptive flexion reflex
(not blinded studies), and class III for corneal reflex and blink
reflex. The grade of recommendation is C and B respectively. As for
exteroceptive suppression of masticatory muscle activity, only few
blinded studies (class III) fail to confirm previous investigations: the
grade of recommendation is C.*

**Autonomic Tests**

Studies of autonomic functions in migraine and cluster headache were
mostly focused on autonomic systems innervating specific target organs
which, anatomically and functionally, are not necessarily related to the
supposed autonomic origin of the pain. Autonomic parameters are
confounded by effector organ response characteristics. Therefore, there
is no clear evidence justifying the recommendation of autonomic tests
for the routine clinical examination of headache patients.

*This is a class IV level of evidence and the grade of recommendation is
C.*

**Clinical Tests, Pressure Pain Thresholds (PPTs), and Electromyography
(EMG) (with Special Reference to TTH)**

Tenderness recorded by manual palpation is the most specific and
sensitive test in patients with TTH, and can therefore be recommended as
a routine clinical test in contrast to EMG and pressure pain thresholds.
However, this manual palpation is non-specific and cannot be used to
discriminate between different coexisting primary or secondary
headaches.

*This is a class IV level of evidence and the grade of recommendation is
C (few blinded studies mainly concerning methodology in healthy
volunteers).*

**Neuroimaging**

When neuroimaging is warranted, the most sensitive method should be
used, and magnetic resonance imaging (MRI) and not computed tomography
(CT) is recommended in these cases.

*The grade of recommendation is C, as most studies are non-analytical
and although there exist a few randomized clinical trials, some of them
are not directly relevant to these recommendations (class IV).*

Specific recommendations are:

1.  In adult and paediatric patients with migraine, with no recent
    change in pattern, no history of seizures, and no other focal
    neurological signs or symptoms, the routine use of neuroimaging is
    not warranted.

2.  In patients with atypical headache patterns, a history of seizures,
    and/or neurological signs or symptoms, or symptomatic illness such
    as tumours, acquired immunodeficiency syndrome (AIDS), and
    neurofibromatosis, MRI may be indicated (to be carefully evaluated
    in each case).

**Single-Photon Emission Computed Tomography (SPECT) and Positron
Emission Tomography (PET)**

If attacks can be fully accounted for by the standard headache
classification (International Headache Society), a PET or SPECT scan
will generally be of no further diagnostic value. Nuclear medicine
examinations of cerebral circulation and metabolism can be carried out
in subgroups of headache patients for diagnosis and evaluation of
complications. Regional cerebral blood flow (rCBF) recordings can be of
particular value in patients in whom the standard classification
(International Headache Society) cannot be fully applied, when patients
experience unusually severe attacks, or the quality or severity of
attacks has changed. rCBF recordings should then be carried out both
during an attack (if possible several repeated scans) and interictally
(at a time interval of \>5 days after an attack). Quantifiable rCBF
measurements are preferable to distribution images.

*This is a class IV level of evidence, i.e., most studies are case
reports or case series, and therefore the grade of recommendation is C.
There is insufficient evidence to make specific recommendations.*

**Transcranial Doppler**

Transcranial Doppler examination is not helpful in headache diagnosis.
It is, however, a non-invasive examination with excellent temporal
resolution which is useful for studying the vascular aspects of the
headache pathophysiology and the vascular effects of anti-headache
medication. The information obtained using this method is easier to
interpret if side-to-side comparisons are made or if it is combined with
rCBF measurements.

*This is a class IV level of evidence and the grade of recommendation is
C.*

**[Definitions]{.underline}**:

**Evidence Classification Scheme for a Diagnostic Measure**

**Class I**: A prospective study in a broad spectrum of persons with the
suspected condition, using a \'gold standard\' for case definition,
where the test is applied in a blinded evaluation, and enabling the
assessment of appropriate tests of diagnostic accuracy

**Class II**: A prospective study of a narrow spectrum of persons with
the suspected condition, or a well-designed retrospective study of a
broad spectrum of persons with an established condition (by \'gold
standard\') compared to a broad spectrum of controls, where test is
applied in a blinded evaluation, and enabling the assessment of
appropriate tests of diagnostic accuracy

**Class III**: Evidence provided by a retrospective study where either
persons with the established condition or controls are of a narrow
spectrum, and where test is applied in a blinded evaluation

**Class IV**: Any design where test is not applied in blinded evaluation
OR evidence provided by expert opinion alone or in descriptive case
series (without controls)

**Rating of Recommendations**

**Level A rating**: (established as useful/predictive or not
useful/predictive) requires at least one convincing class I study or at
least two consistent, convincing class II studies

**Level B rating**: (established as probably useful/predictive or not
useful/predictive) requires at least one convincing class II study or
overwhelming class III evidence

**Level C rating**: (established as possibly useful/predictive or not
useful/predictive) requires at least two convincing class III studies

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is identified and graded for selected
recommendations (see \"Major Recommendations\").

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Accurate diagnosis of non-acute headache

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

-   As this paper was going to press, the new International Headache
    Society Classification of Headache Disorders was published
    (Cephalalgia 2004, vol. 24, Suppl. 1). This key reference includes
    clinical and instrumental diagnostic criteria for differentiating
    between primary and secondary headaches and its consultation is
    strongly recommended.

-   The present guidelines and recommendations are intended to furnish
    the reader with information, based on the evidence in the
    literature, concerning the usefulness of instrumental investigations
    in non-acute headache; clearly, however, each clinical judgment is
    the responsibility of the physician(s) concerned

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The European Federation of Neurological Societies has a mailing list and
all guideline papers go to national societies, national ministries of
health, World Health Organisation, European Union, and a number of other
destinations. Corporate support is recruited to buy large numbers of
reprints of the guideline papers and permission is given to sponsoring
companies to distribute the guideline papers from their commercial
channels, provided there is no advertising attached.

#### IMPLEMENTATION TOOLS

Staff Training/Competency Material

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness

#### IOM DOMAIN

Effectiveness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Sandrini G, Friberg L, Janig W, Jensen R, Russell D, Sanchez del Rio M,
Sand T, Schoenen J, van Buchem M, van Dijk JG. Neurophysiological tests
and neuroimaging procedures in non-acute headache: guidelines and
recommendations. Eur J Neurol 2004 Apr;11(4):217-24. \[43 references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=15061822)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 Apr

#### GUIDELINE DEVELOPER(S)

European Federation of Neurological Societies - Medical Specialty
Society

#### SOURCE(S) OF FUNDING

European Federation of Neurological Societies

#### GUIDELINE COMMITTEE

European Federation of Neurological Societies Task Force

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Task Force Members*: G. Sandrini, University Centre for Adaptive
Disorders and Headache, IRCCS C. Mondino Foundation, Pavia, Italy; L.
Friberg, Department of Clinical Physiology and Nuclear Medicine,
Bispebjerg Hospital, Copenhagen, Denmark; W. Jänig, Physiologisches
Institut, Christian-Albrechts-Universität, Kiel, Germany; R. Jensen,
Department of Neurology, Glostrup Hospital, University of Copenhagen,
Glostrup, Denmark; D. Russell, Department of Neurology, Rikshospitalet,
Oslo, Norway; M. Sanchez del Rìo, Department of Neurology, Hospital
Ruber Internacional, Madrid, Spain; T. Sand, Department of Neurology,
Norwegian University of Science and Technology, Trondheim, Norway; J.
Schoenen, University Department of Neurology, CHR Citadelle, Liege,
Belgium; M. van Buchem, Department of Radiology, Leiden University
Medical Centre, Leiden, The Netherlands; J. G. van Dijk, Department of
Neurology and Clinical Neurophysiology, Leiden University Medical
Centre, Leiden, The Netherlands

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

#### GUIDELINE AVAILABILITY

Electronic copies: Available to registered users from the [European
Federation of Neurological Societies Web
site](http://www.efns.org/content.php?pid=142).

Print copies: Available from Giorgio Sandrini MD, University Centre for
Adaptive Disorders and Headache, IRCCS C. Mondino Foundation, Via
Palestro 3 -- 27100 Pavia, Italy; E-mail: <gsandrin@unipv.it>

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Brainin M, Barnes M, Baron JC, Gilhus NE, Hughes R, Selmaj K,
    Waldemar G; Guideline Standards Subcommittee of the EFNS Scientific
    Committee. Guidance for the preparation of neurological management
    guidelines by EFNS scientific task forces -- revised
    recommendations 2004. Eur J Neurol. 2004 Sep;11(9):577-81.
    Electronic copies: Available in Portable Document Format (PDF) from
    the [European Federation of Neurological Societies Web
    site](http://www.efns.org/files/guideline_23.pdf).

-   Guideline papers. European Federation of Neurological Societies.
    Electronic copies: Available from the [European Federation of
    Neurological Societies Web
    site](http://www.efns.org/content.php?pid=141).

-   Continuing Medical Education questions available from the [European
    Journal of Neurology Web
    site](http://www.blackwellpublishing.com/products/journals/ene/mcqs/).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on August 24, 2006. The
information was verified by the guideline developer on October 25, 2006.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the Blackwell-Synergy copyright restrictions.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008