When the Brain MRI is Normal but Something Still Feels Wrong…

Many of the patients who come to see me have already had an MRI of the brain.

The report often says that everything is normal, or that there are only a few non-specific changes of no obvious clinical significance.

This should be reassuring. And, of course, in many ways it is.

There is no brain tumour. No stroke. No clear inflammation, hydrocephalus or other structural explanation for the symptoms.

But the patient sitting in front of me still does not feel well.

They may have dizziness, numbness, headaches, fatigue, problems with concentration or a feeling that something has changed in the way their body works. Sometimes they find it difficult even to describe what is wrong. They simply know that they do not feel like themselves.

Many have already been told that the MRI is normal. What they have not always been told is what that actually means.

A normal brain MRI means that we cannot see a structural abnormality that explains the symptoms. It does not mean that the symptoms are not real, and it does not necessarily mean that the brain is functioning normally.

I think this distinction is important.

Medicine is good at finding many of the things we have learned to look for. We can recognise tumours, strokes, inflammation and characteristic patterns of several neurological diseases. We are particularly good at identifying what is dangerous, visible and sometimes treatable.

But there is still a great deal that an MRI cannot show.

Migraine usually does not appear on a brain MRI. Neither do many causes of dizziness, fatigue, pain or cognitive symptoms. The scan gives us a detailed image of structure, but only limited information about how the different networks of the brain are working together from one moment to the next.

This is also relevant in functional neurological symptoms. These symptoms are real and involuntary, but they are related to changes in how the nervous system functions rather than to structural damage visible on a conventional MRI.

Unfortunately, patients with functional symptoms have sometimes been left with the impression that nothing is wrong because nothing can be seen.

That is not a useful way to understand them.

At the same time, I am careful not to conclude that symptoms are functional simply because an MRI is normal. A normal scan is not a diagnosis. It is one piece of information that must be considered together with the person’s history, neurological examination and the development of the symptoms over time.

I often think that it is easier to have a diagnosis than to have unexplained symptoms.

A diagnosis may be frightening, but at least it gives the experience a name. When tests are normal and no explanation is offered, patients may begin to doubt themselves. Some become afraid that other people see them as hypochondriacs. Eventually, they may even begin to wonder whether they are imagining what they feel.

Usually, they are not.

Sometimes I can explain the symptoms. Sometimes I can identify a pattern and suggest what we should do next. And sometimes I have to say that I do not yet know.

I do not think that uncertainty means that the symptoms should be dismissed. It means that our current methods have not provided the whole answer.

A normal brain MRI can exclude many important conditions. That is valuable, and often very reassuring.

But it cannot show us everything that can go wrong in a brain.

And it certainly cannot tell us that the person sitting in front of us feels well.

Dr Jessika Nystedt