Mass Lesions (as cause of Chronic H/A)

Who needs an image for chronic headache to rule-out CNS disease?

Abnormal neuro exam;
Progressive headache;
Red Flags:
1. Associated with daily nausea / vomiting;
2. Softer clue: worsening with valsalvas or bending forward. Contrary to popular opinion, early morning onset is not a feature;
3. Elderly patients, & those taking anticoagulants, who can have occult subdural hematomas [“elderly” sometimes defined as “over 50”];
4. Persons over 50 with a completely new headache are more likely to have tumors.

A non-contrast CT should suffice. MRI is more sensitive for masses overall, but not necessarily for those large enough to cause headache.