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This article is for Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find the X-ray Test article more useful, or one of our other health articles.

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Headache and head trauma are common presenting problems in both primary care and the Accident and Emergency department. Plain skull X-ray (SXR) films (plain skull films) have largely been superseded by CT scanning and/or MRI scans in the context of both headaches and head injuries[1]. This is also true in paediatric patients. Validated clinical tools do exist for evaluating the need for further imaging when the head trauma is fairly minor[2].

There is useful literature on the pre-hospital management of head injury and concussion[3, 4].

SXRs are still useful where safeguarding investigations are being undertaken, to detect healing/healed injuries[5]. International guidelines for skeletal survey have been published by the American College of Radiology and the Society for Pediatric Radiology and the Royal College of Radiologists and the Royal College of Paediatrics and Child Health. According to both guidelines, a complete radiographic series comprises at least 20 images and includes frontal and lateral skull views as a minimum[6].

When to request a skull X-ray
Head injury or not
Clinical settings
Head injury
CT scanning is the recommended investigation and criteria for CT scanning are provided in the National Institute for Health and Care Excellence (NICE) guidance[1].
Non-head injury cases
  • Presence of a palpable vault abnormality which feels bony.
  • As part of an imaging protocol for specific clinical problems - eg, skeletal survey for myeloma. Many centres now prefer bone scans for this purpose.
  • Facial views after trauma to the facial skeleton, mandible or orbit, or the possibility of a metallic foreign body.

Skull films are not indicated routinely for the following indications:

  • Headache.
  • Possible pituitary problems - (CT/MRI preferred).
  • Possible space-occupying lesion.
  • Epilepsy.
  • Dementia or memory loss.
  • Middle or inner ear problems.
  • Nasal trauma - coned views may be requested by the appropriate specialist.
  • Sinus disease - mucosal thickening is a common incidental finding and not diagnostic.
  • Temporomandibular joint dysfunction - will not show disc abnormality, which is the most common cause of dysfunction.

Skull films should be interpreted wherever possible by a doctor with specialist radiological training and/or considerable experience in interpreting such films. In untrained hands approximately 10% of bony abnormalities are not recognised. The absence of a fracture on a skull film does not rule out the possibility of an operable intracranial haematoma in head-injured patients, which is why CT scanning is the investigation recommended in significant head injuries[1]. All such findings must be taken in the context of the clinical condition of the patient.

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Further reading and references

  1. Head injury: assessment and early management; NICE Clinical Guideline (January 2014, updated September 2019)

  2. Mastrangelo M, Midulla F; Minor Head Trauma in the Pediatric Emergency Department: Decision Making Nodes. Curr Pediatr Rev. 201713(2):92-99. doi: 10.2174/1573396313666170404113214.

  3. Brain Trauma Foundation; Guidelines for prehospital management of traumatic brain injury, 2007

  4. Chowdhury T, Kowalski S, Arabi Y, et al; Pre-hospital and initial management of head injury patients: An update. Saudi J Anaesth. 2014 Jan8(1):114-20. doi: 10.4103/1658-354X.125971.

  5. Davis T, Ings A; Head injury: triage, assessment, investigation and early management of head injury in children, young people and adults (NICE guideline CG 176). Arch Dis Child Educ Pract Ed. 2015 Apr100(2):97-100. doi: 10.1136/archdischild-2014-306797. Epub 2014 Oct 21.

  6. Nguyen A, Hart R; Imaging of non-accidental injury what is clinical best practice? J Med Radiat Sci. 2018 Jun