S1 E3: Do I Need a Brain Scan?

Do I Need a Brain Scan?

Series 1, episode 3

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Transcript:

 

[00:00:00] Did you know worldwide, only 40 percent of those with migraine are professionally diagnosed? There’s help out there. Welcome to the Head’s Up podcast brought to you by the National Migraine Centre, the only UK charity treating migraine and headache.

 

Dr Katy Munro [00:00:23] Hi, I’m Katy and I’m with Jess, we’re your GP headache specialists from the National Migraine Centre.

 

Dr Jessica Briscoe [00:00:30] Hello.

 

Dr Katy Munro [00:00:32] So today we’re going to talk about brain scans because people with headaches often worry that they’re going to have some sort of tumour or nasty thing. And people who get migraines coming thick and fast wonder if there’s something else going on. So they often ask us, do I need a brain scan? And sometimes they come and see us and they’ve already had one. What do you say to people who say that?

 

Dr Jessica Briscoe [00:00:54]  To be honest, most of the time I say no, but it very much depends on their individual cases. So there are some people where actually we do think that brain scan would be needed and they’re people where we worry that something more concerning may be going on. So if you are someone who is known to have migraine, you’ve got a very classical history. You might have had a bit of a change in your migraine, which is within keeping for normal migraine pattern, then I wouldn’t advise having a scan. But if you have any of these more concerning issues, then we should be thinking of them.

 

Dr Katy Munro [00:01:30] Yes. So one of the things we hear about is the so-called thunderclap headaches. So that’s where somebody says, well, I had a sudden, really severe headache that hit me. It was very different from my normal headaches and it came on as if somebody hit me on the back of the head with a baseball bat. And that could be people who never usually have headaches or it can be people who have migraine, but then they suddenly get one that’s very different. So those are the ones that I send to casualty or say go and quickly get some investigations done because that can be the sign of a bleed inside the head.

 

Dr Jessica Briscoe [00:02:04] And that needs emergency treatment.

 

Dr Katy Munro [00:02:06] Yeah, we don’t deal with that on a general day to day basis and we hardly ever see at the National Migraine Centre. It’s not really the kind of thing that presents to us, is it?

 

Dr Jessica Briscoe [00:02:15] No. I think the next type is if you’ve ever had- if there’s any chance that you could have a cancer that spread to the brain. So if you’re someone who’s suffered with certain cancers like lung cancer, breast cancer, thyroid, kidney cancers or melanoma, and you’ve got a new type of headache, sometimes we would suggest a scan in those cases.

 

Dr Katy Munro [00:02:36] So the emphasis is really on new, different severe types of headache that are not typical. So the other thing is, if we’re doing a neurological examination on somebody and we find that something is persisting so they might have a weakness or they might have some signs when we’re examining their eyes. And so often we tell people to go and get the opticians to have a look in their eyes. Opticians have brilliant equipment now as well. But it’s really that sort of, what we call, red flag things, isn’t it? Things that make us think, well, this isn’t just migraine, because in itself, migraine doesn’t need a brain scan.

 

Dr Jessica Briscoe [00:03:17] And I think everyone always says that I know somebody who had a brain tumour and it was caused by a headache. I mean, actually, from a medical point of view, the majority of brain tumours do not present with headaches. That as a general rule, I think everybody knows someone who’s had one, but generally speaking, the likelihood of people having it without any other abnormalities in examination or something just being unusual in the story.

 

Dr Katy Munro [00:03:45]  There was a study of children and it showed that a lot of children who were diagnosed with brain tumours did get headaches, but they also had other neurological features. So that means that something about their nervous system, when they were examined by the doctor, wasn’t right. So I think obviously people who have children with a lot of headaches do need to be careful to go and see their GP and have a chat about whether or not a brain scan is needed. But just as a knee jerk reaction to somebody with classic history of migraine, it isn’t essential. And in fact, it can be misleading.

 

Dr Jessica Briscoe [00:04:19] Yeah, it’s actually- there’s a thing called an incidentaloma which is where people have very concerning or seemingly concerning features on a scan that often aren’t problematic and can cause more harm than good when they look at-when we find them.

 

Dr Katy Munro [00:04:36] It just makes them anxious, really, doesn’t it?

 

Dr Jessica Briscoe [00:04:38] Yeah, and there is actually very good evidence that the anxiety- because everyone says, why don’t we just give everyone a scan, you know, if it’s going to let my mind set to rest, why don’t we all just have a scan? Actually, the evidence shows that having a scan only causes reassurance for a certain amount of time, usually actually only a year. And then people feel that they want to have more and more elaborate scans. So actually, it doesn’t tend to reassure people very much.

 

Dr Katy Munro [00:05:06] In the occasional cases where people do need a scan there are two main types, aren’t there? There is a CT scan and there’s an MRI scan. The CT scan causes a radiation, it’s like an X-ray. The MRI scan is the one which people have to lie very, very still and it’s also quite a noisy scan, isn’t it?

 

Dr Jessica Briscoe [00:05:28] Yeah, I think it can feel very claustrophobic, can’t it? People can get quite- they’re quite unpleasant.

 

Dr Katy Munro [00:05:33] Yeah. It doesn’t give you any radiation though, so it’s useful and scans for the right reasons can be really helpful.

 

Dr Jessica Briscoe [00:05:41] Yeah. So I think in summary what we’re saying is the majority of people with a change in their normal migraine, which isn’t out of the ordinary, don’t need a scan. If you’re concerned at all, you need to see your doctor and probably your optician as well, because you can get a lot of good information from them and discuss whether or not a scan is needed. But if they feel that it isn’t, they’re probably right.

 

Dr Katy Munro [00:06:08] All right, now we’re going to have a chat with my friend and colleague, Dr. Naz Manukyan.

 

Dr Naz Manukyan [00:06:13] Hello.

 

Dr Katy Munro [00:06:14] Hello there, Naz. We’ve been practising pronouncing your name properly. We’re going to talk a bit more about brain scans and why and when we advise them or actually do we not advise them? So how do you- if patients are thinking that they really do need a scan, how do you explain and reassure them that their headaches don’t need an MRI scan?

 

Dr Naz Manukyan [00:06:35] I find taking time and listening to patients can be quite reassuring. And then when you perform neurological examination and it’s completely normal. As our colleague Dr. Elkington would say, you are normal at the end of an examination.

 

Dr Katy Munro [00:06:51] Neurologically normal is always reassuring, isn’t it?

 

Dr Naz Manukyan [00:06:54] Yes. And then I find following that I would explain that brain anatomy is such a compact structure full of nerve fibres controlling all our body functions. If there was some tiny lesion of tumour growing, initially, it would affect the functions so we have a loss of speech, weakness in the arm, loss of sensation, loss of vision and headaches are not presenting future of tumours, as we discussed. Usually it would be seizures or neurological problems first.

 

Dr Katy Munro [00:07:25] And it’s the persistence of those changes that gives us the clues, isn’t it? Because we know that if people are having episodes of migraine, they’re completely fine in between.

 

Dr Naz Manukyan [00:07:35] Yes, it becomes a bit more difficult to reassure people when they have a chronic form of migraine. They have daily headache and if this is a new change. So they used to have typical migraine attacks but somehow, later on, they developed every day more persistent headaches then most likely we have to have a scan.

 

Dr Katy Munro [00:07:54] Yes, sometimes it’s for our reassurance as much as anything, isn’t it, when things are changing? So there are some sort of special types of migraine that people present to us with so either hemiplegic migraine or people talk about vestibular migraine. Would you think about a scan in those cases more?

 

Dr Naz Manukyan [00:08:12] If it was their first presentation and suddenly without any obvious migraine story- preceding history, they develop new persistent vertigo or visual disturbances, it hasn’t cleared after a migraine attack. So for the first time round, I think it’s important, as you said, to reassure us and the patient and explain why their symptoms haven’t gone away. It’s not very typical of migraine.

 

Dr Katy Munro [00:08:36] Yeah. So it’s if it’s a typical story of migraine classical symptoms that go away in between, there’s really no need for a scan. But if things are a little bit out of the ordinary or changing, then we would have more of a threshold to send for a scan. And sinuses and neck can be a problem. And people often come when they have a lot of history of pains in their sinuses or going down into the neck. Do they need scans?

 

Dr Naz Manukyan [00:09:01] So I find this is the commonest cause they would seek a scan or end up seeing specialists like ENT doctors because the migraine pain is localised in their sinuses or they have dental problems, pain in the mouth or in the tongue, in the cheek or in the neck. So they see their osteopath and they try to rule out structural problems with the neck. So they would be referred and have an MRI of their cervical spine or have an MRI of their sinuses, CT of sinuses.

 

Dr Katy Munro [00:09:32] So it can be helpful, but it’s not something they have to have. And it may be that they’ve got sinus or neck pain from their actual migraines.

 

Dr Naz Manukyan [00:09:41] That’s right. And we, you know, so far in our clinic, we haven’t seen people who had ay abnormality picked up. So most of them had already had scans, they’ve seen a few neurology or headache specialists and they’re still not reassured.

 

Dr Katy Munro [00:09:54] We recently did a poll on our Facebook page and on Twitter, and we asked people whether they’d had a brain scan and about 61 percent of people replied that they had had a brain scan. And a couple of things came up. One of the things was the Chiari malformation. Can you tell us a bit about that?

 

Dr Naz Manukyan [00:10:13] Yes, I had a patient myself. It was a girl who since teens developed episodic headaches, they were a bit unusual. They were related only to exercise. So she was trying to do some weight lifting recently in the gym and each time after a few minutes of exercise, she would get extremely severe pain, lasting 30 minutes and going away completely with no other obvious triggers.

 

Dr Katy Munro [00:10:38] So very specific situations.

 

Dr Naz Manukyan [00:10:45] So when asking directly about any signs of increased pressure in the brain, and she would on coughing or straining, she would also get episodes of pain. So I was a bit worried and wanted exactly to rule out something like Chiari malformation or intracranial hypertension.

 

Dr Katy Munro [00:11:01] So what is Chiari malformation? Can you just describe that for us?

 

Dr Naz Manukyan [00:11:05] So it’s a malformation or a structural problem when the low part of the brain, base of the brain pushes down out of the skull and presses into the spinal area, and it blocks the normal circulation of cerebral spinal fluid.

 

Dr Katy Munro [00:11:21] So a completely separate thing from migraine?

 

Dr Naz Manukyan [00:11:23] That’s right.

 

Dr Katy Munro [00:11:24] And do you know how common that is?

 

Dr Naz Manukyan [00:11:26] I don’t think it’s very common, it’s rare, but it can present in teens and young girls. And the mildest form of that, the Chiari 1, which is, you know, very mild compression, can present with migraine, episodic headache. More serious advanced ones they can have lots of neurological symptoms as well.

 

Dr Katy Munro [00:11:47] So something for doctors to be aware of but actually it’s much less common than the migraine that we see every week. So the other thing that comes up is sometimes people are told that they have white matter changes on their scans and that can raise people’s anxiety quite a lot. So what do we think about that?

 

Dr Naz Manukyan [00:12:06] This is the commonest finding when they’re told, oh, your MRI is normal, but you have some white matter changes. Which is areas of increased brightness we see on MRI scan and we’re not quite sure what is the significance of that. About 43 percent of those migraineurs who had a scan have these changes and we think migraine with Aura gives more appearance of white matter changes. So it can be quite worrying because patients then are told you could have multiple sclerosis and they will need to have repeat scans to see whether the white matter changes are worsening. And we don’t know what’s the underlying reason for them and are they cause or consequence of migraines.

 

Dr Katy Munro [00:12:51] And they are significant? And I mean, that can be very worrying then for patients. If they’re told, this might be something horrible and you have to have more. So this is where I think some of the other headache specialists have said, you know, the radiologists need to be really careful when they’re reporting those kind of scans and recognise that is a frequent finding in people with migraine.

 

Dr Naz Manukyan [00:13:13] Yes, they call them white signal changes or small vessel disease. It’s quite common in older patients and it can increase with age. And there is ongoing research whether it could be a marker of brain frailty and maybe a marker of some future problems.

 

Dr Katy Munro [00:13:32] But we don’t really know enough about it so it’s, as you said, is this caused by migraine or is it causing a migraine? And there’s still a big question mark over that but I think the message is really don’t panic if that is on your report.

 

Dr Naz Manukyan [00:13:47] That’s right.

 

Dr Katy Munro [00:13:48] And I think we’re going to be hearing from a patient later in the podcast who has had a lot of experience of different scans and led her on to having all sorts of other tests, including lumbar punctures and what she felt about having that. OK, that’s great. Thanks very much.

 

Dr Naz Manukyan [00:14:04] Thank you.

 

Dr Katy Munro [00:14:05] So now we’re going to be hearing from Charlotte, had a chat with Caitlin and her experience with having scans.

 

Charlotte [00:14:14] Hello, Caitlin, thank you for joining our podcast, we are discussing brain scans for this one. And so I understand that you’ve had a brain scan yourself.

 

Caitlin [00:14:22] Yes, thanks for having me. I’ve had three brain scans.

 

Charlotte [00:14:25] Three. Oh, my gosh. And was it recommended to you to have it or did you request it?

 

Caitlin [00:14:31] No, it was recommended to me by my GP at the time, although I was having thoughts, it was getting to the point that I was considering requesting one anyway.

 

Charlotte [00:14:41] OK, and what scans did you have then if you had three?

 

Caitlin [00:14:44] I had an MRI and a CAT scan initially and then two years later, I did have to have a follow up one.

 

Charlotte [00:14:51] OK, what was it like actually having the scan itself? Is that quite scary?

 

Caitlin [00:14:56] No, it wasn’t scary. I think if you were claustrophobic, though, that wouldn’t be too fun for you. But the people who were there put me at ease. They explained step by step what I’d be experiencing. It’s quite loud when you’re in the machines, but it’s over before, you know it. Not really scary at all.

 

Charlotte [00:15:13] OK, well, that’s quite good. And what did they find then? What were the findings?

 

Caitlin [00:15:17] So they found that I have what they called undiagnosed brain lesions. So 13 to 15, I don’t quite remember now, brain lesions which just showed up as like little white matter on my brain scan.

 

Charlotte [00:15:29] OK. So was this to do with migraine then or nothing to do with it?

 

Caitlin [00:15:33] So that’s the thing, we don’t actually know after all of that.

 

Charlotte [00:15:37] Oh, really?

 

Caitlin [00:15:37] I went to a neurologist with these scans and they said it did not look like a typical pattern of someone with a neurological disorder. And many people do just have brain lesions. So brain damage that shows up and we may never actually know what has caused it, why it’s there. It could be that my migraines, my really bad ones in the beginning caused it. It could be something completely unrelated and to this day, I still don’t know.

 

Charlotte [00:16:03] Has it helped with the management of migraine then in any way?

 

Caitlin [00:16:07] No, it has not helped my management.

 

Charlotte [00:16:09] And did you find it useful? Would you have done it again if you could? Do you think it’s like made you feel more ease or?

 

Caitlin [00:16:16] At the time it was really stressful. It was- to go through those scans because I had a six month episode of a migraine. So they were starting to think that it wasn’t that I was a migraine sufferer, I did have a neurological condition. That’s why they requested the scan. And then I got a phone call saying they found abnormalities and that just was so stressful. Triggered my migraine form the stress. And till I sort of did more research into it and sat down with a doctor and properly understood that it could be nothing, to this day, I just, it’s nothing. So it hasn’t helped my migraines in that sense. But the follow up I had to do two years later was to see if they had changed or grown in any way and they hadn’t. And so that was really reassuring. Yeah, that was reassuring. There was damage, what’s caused it, who knows? But it’s there. It’s not progressing. It’s not getting worse. And, you know, from the perspective of do I have a neurological condition? No, I don’t. That was really reassuring. At the time, my friend and I joked we called them my brain bubbles just to make them sound a little less scary.

 

Charlotte [00:17:17] Well i think that’s going to be really helpful for our listeners just to know that if they do have a brain scan and things do come up, that it’s not necessarily as scary as it sounds.

 

Caitlin [00:17:26] Yeah, I know.

 

Charlotte [00:17:27] Well, thank you. I think that’s been so helpful. And so thank you very much for joining us.

 

Caitlin [00:17:32] Thank you for having me.

 

Dr Katy Munro [00:17:36] Thank you for listening to this episode of the Heads Up podcast, our next edition is a special extended edition for Migraine Awareness Week. Our topic is going to be mental health and migraine and we’re delighted that Iain Lee, writer, broadcaster, podcaster and comedian, has contributed some material for this episode. We’ll also be hearing from other specialists and patients. So listen in next time.

 

[00:18:04] You’ve been listening to the heads up podcast, if you want more information or have any comments, emails us at info@NationalMigraineCentre.org.uk. Till next time.