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Imaging for headaches is one of the most frequent and at times challenging decisions a neurologist has to make in the clinical practice of neurology and is complicated by today’s medical-legal milieu and overseeing regulatory organizations. Although the final decision should always be made by the treating physician, the American Academy of Neurology has developed practice parameters for the imaging of headaches. One strong criticism of the overzealous use of neuroimaging in patients with headache is the frequency of incidental findings, which may in turn increase a patient’s anxiety and potentially cause an exacerbation of symptoms. This may subsequently lead to unnecessary testing as well as neurosurgical intervention. The clinical interpretation of incidental findings and headaches is best made by a neurologist who is able to correlate the imaging findings with the patient’s symptoms and examination. One of the principal precepts in medicine, “primum nil nocere” or “first, do no harm” to patients, should be considered in the interpretation of these so-called abnormalities. The development of programs to certify competence in physicians who have completed accredited training programs in neuroimaging as well as headache medicine by the United Council for Neurologic Subspecialties is an important advancement that allows clinicians the opportunity to enhance quality of patient care.

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