Neuroimaging is necessary in migraine patients in which circumstances?

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Neuroimaging in migraine is guided by warning signs that suggest a secondary headache rather than a primary migraine. The key idea is that imaging isn’t needed for typical, uncomplicated migraines, but is warranted when there are red flags or an abnormal neurologic examination. An abnormal neurologic exam flags possible structural or focal pathology. Red flags to consider include a headache that is the first or worst of life, a change in headache pattern, headaches that persist on the same side, headaches not responding to treatment, onset after age 50, fever with neck stiffness, and cognitive impairment or personality changes. In these situations imaging helps rule out serious causes such as masses, hemorrhage, infection, or other intracranial processes, which would alter management. The other options fall short because imaging isn’t required in all cases (not always), and there are scenarios where imaging is clearly indicated (red flags or abnormal exam).