Headache is among the most common reasons people visit a neurologist. Most of us associate a headache with having the head scanned with modern imaging techniques such as CT and MRI, assuming the scan will set everything straight. To help readers better understand this, I would like to learn from our experts today.
Welcome, Dr Haseeb Hassan, Senior Neurologist at Healthcare Scan Diagnostics, and Dr Arif Faizan, Senior Radiologist and Head of Catalyst Imaging.
eNewsroom: My first question is for Dr Hassan. Headache is extremely common. Can you give our readers an overview?
Dr Haseeb Hassan: Almost everyone experiences a headache at some point in life. Fortunately, nearly 90 to 95 percent of headaches seen in routine clinical practice are primary headache disorders, such as migraines or tension-type headaches. These are not caused by a brain tumour or a stroke. A much smaller proportion are secondary headaches, where the headache is a symptom of another medical condition, such as bleeding in the brain, infection, stroke, raised intracranial pressure, or, rarely, a brain tumour. These headaches are fewer in number, but missing them can have serious consequences. The first task of a neurologist is to distinguish between these two groups through a detailed history and neurological examination.
eNewsroom: What imaging options are available today for evaluating headaches?
Dr Arif Faizan: Depending on the clinical suspicion, referring doctors request different scans and frequently involve us in deciding the best approach. The most appropriate investigation depends entirely on the clinical question raised by the treating physician. There are several common imaging modalities we rely on. A non-contrast CT of the brain is best for emergencies, such as trauma or a suspected brain haemorrhage, while a contrast-enhanced CT is often used for selected infections or tumours. When we need excellent, high-resolution detail of brain tissue, an MRI of the brain is the preferred choice. For vascular concerns, we use CT Angiography to rapidly detect aneurysms or arterial blockages, and MR Angiography to evaluate the arteries supplying the brain. We also utilise MR Venography to assess venous sinuses, especially when cerebral venous thrombosis is suspected.
eNewsroom: Many people feel that unless they have an MRI, they cannot be sure that their headache isn’t due to a brain tumour. How do you approach such patients? Is it not logical to get the MRI done to reassure your patients?
Dr Haseeb Hassan: This is one of the most common situations we encounter in clinical practice. Understandably, patients are anxious, and many believe that every persistent headache could indicate a brain tumour. The fear of a brain tumour is deeply embedded in the public’s mind. Popular movies, television serials, and even social media often portray a persistent headache as the very first sign of a brain tumour. While this makes for dramatic storytelling, it is simply not how headaches present in the overwhelming majority of people. My first responsibility is not to order a scan immediately, but to understand the headache in detail. If a careful history and neurological exam show no red flags, international headache guidelines generally advise against routine MRI because it is unlikely to change the diagnosis or treatment. As neurologists, one of our key roles is to replace fear with facts. The best reassurance comes from an expert clinical assessment rather than imaging performed simply because of anxiety.
Dr Arif Faizan: I completely agree. MRI is an extremely sensitive investigation, but that sensitivity brings its own challenges. We frequently identify incidental findings—small benign cysts, age-related white matter changes, or developmental anatomical variations that have absolutely nothing to do with the patient’s headache. Although these findings are harmless, patients often become worried simply because something abnormal was mentioned in the report, which triggers unnecessary anxiety and repeat imaging. A normal MRI tells us there is no significant structural brain disease, but it does not mean that the patient’s headache isn’t genuine or that a migraine isn’t present.
Dr Haseeb Hassan: Exactly. I have often seen patients become more anxious after an MRI rather than less anxious, especially when they read terms in the report that sound alarming but are actually clinically insignificant. Research has shown that for patients with typical primary headaches, a routine MRI does not consistently provide long-term reassurance. People misunderstand what an MRI actually does. It detects structural abnormalities, but primary headache disorders like migraines arise from complex functional, neurovascular, and neurochemical processes that are simply not visible on a routine scan.
eNewsroom: Dr Hassan, you mentioned at the start regarding some dangerous causes of headache that need urgent attention. When should someone with a headache seek urgent medical attention?
Dr Haseeb Hassan: Anyone experiencing a sudden, severe thunderclap headache should seek immediate medical attention. Similarly, a headache associated with weakness or numbness of the limbs, difficulty speaking, double vision, loss of vision, confusion, altered consciousness, or seizures should never be ignored. Other warning signs include fever with neck stiffness, which may indicate an infection of the brain, persistent or recurrent vomiting, a headache following a significant head injury, or a headache that progressively worsens over days or weeks. These symptoms require prompt medical evaluation and urgent brain imaging to identify the cause and initiate timely treatment.
Dr Arif Faizan: Ironically, we often observe the opposite of what we would ideally expect in these urgent scenarios. Patients with sudden-onset, potentially dangerous headaches sometimes delay the scan because the pain begins to improve. They assume it is just a bad headache. Unfortunately, conditions such as a brain haemorrhage or certain types of strokes can initially present this way, and delaying imaging postpones life-saving treatment. On the other hand, patients with long-standing, recurrent headaches are often keen to undergo repeated MRI scans, hoping to finally reveal a structural cause for their functional suffering.
eNewsroom: What are the common mistakes people make regarding headaches and brain imaging?
Dr Haseeb Hassan: The two biggest mistakes are ignoring dangerous warning signs, which leads to under-investigation, and assuming every single headache requires a brain scan, leading to over-investigation. A headache is a symptom, not a diagnosis. Careful history-taking and neurological examination remain the cornerstone of diagnosis.
Dr Arif Faizan: I often tell people coming for a scan at my centre not to ask which scan is better, but rather to ask which scan is appropriate for their condition. CT and MRI are complementary investigations. Brain imaging is one of the greatest advances in modern medicine, but its strength lies in being used appropriately.
eNewsroom: To conclude, what are the key takeaways for our readers?
Dr Haseeb Hassan: Most headaches are not caused by serious brain disease, and a detailed consultation is often more valuable than an immediate scan. You must avoid both under-investigation and over-investigation. Seek urgent medical attention if your headache is sudden, severe, associated with neurological symptoms, fever, seizures, or follows a significant head injury.
Dr Arif Faizan: Remember that CT and MRI answer entirely different clinical questions, so neither is universally better. The best healthcare is not about performing more tests—it is about performing the right test, at the right time, for the right patient.
