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Tsze DS, Kuppermann N, Casper TC, Barney BJ, Richer LP, Liberman DB, Okada PJ, Morris CR, Myers SR, Soung JK, Mistry RD, Babcock L, Spencer SP, Johnson MD, Klein EJ, Quayle KS, Steele DW, Cruz AT, Rogers AJ, Thomas DG, Grupp-Phelan JM, Johnson TJ, Dayan PS. Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol. BMJ Open 2023; 13:e079040. [PMID: 37993148 PMCID: PMC10668138 DOI: 10.1136/bmjopen-2023-079040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 10/16/2023] [Indexed: 11/24/2023] Open
Abstract
INTRODUCTION Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables. METHODS AND ANALYSIS Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model. ETHICS AND DISSEMINATION Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.
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Affiliation(s)
- Daniel S Tsze
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
| | - Nathan Kuppermann
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - T Charles Casper
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Bradley J Barney
- Department of Pediatrics, Division of Critical Care, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Lawrence P Richer
- Women and Children's Health Research Institute, Edmonton, Alberta, Canada
- Department of Pediatrics, Division of Neurology, University of Alberta Faculty of Medicine & Dentistry, Edmonton, Alberta, Canada
| | - Danica B Liberman
- Departments of Pediatrics and Population and Public Health Sciences, Division of Emergency and Transport Medicine, University of Southern California Keck School of Medicine, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Pamela J Okada
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Claudia R Morris
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Emory University School of Medicine, Children's Healthcare of Atlanta, Atlanta, Georgia, USA
| | - Sage R Myers
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jane K Soung
- Department of Pediatrics, Division of Pediatric Emergency Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Rakesh D Mistry
- Department of Pediatrics, Section of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Lynn Babcock
- Department of Pediatrics, Division of Emergency Medicine, University of Cincinnati, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Sandra P Spencer
- Department of Pediatrics, Division of Emergency Medicine, Ohio State University College of Medicine, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Michael D Johnson
- Department of Pediatrics, Division of Pediatric Emergency Medicine, The University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Eileen J Klein
- Department of Pediatrics, Division of Emergency Medicine, University of Washington School of Medicine, Seattle Children's Hospital, Seattle, Washington, USA
| | - Kimberly S Quayle
- Department of Pediatrics, Division of Pediatric Emergency Medicine, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Dale W Steele
- Departments of Emergency Medicine, Pediatrics and Health Services, Policy & Practice, Warren Alpert Medical School and School of Public Health of Brown University, Providence, Rhode Island, USA
| | - Andrea T Cruz
- Department of Pediatrics, Divisions of Emergency Medicine & Infectious Diseases, Baylor College of Medicine, Houston, Texas, USA
| | - Alexander J Rogers
- Departments of Emergency Medicine and Pediatrics, University of Michigan, Michigan Medicine, Ann Arbor, Michigan, USA
| | - Danny G Thomas
- Department of Pediatrics, Section of Emergency Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | | | - Tiffani J Johnson
- Departments of Emergency Medicine and Pediatrics, University of California Davis School of Medicine, University of California Davis Health, Sacramento, California, USA
| | - Peter S Dayan
- Department of Emergency Medicine, Division of Pediatric Emergency Medicine, Columbia University Vagelos College of Physicians and Surgeons, New York, New York, USA
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Ravid S, Gordon S, Schiff A, Shahar E. Headache in children: young age at onset does not imply a harmful etiology or predict a harsh headache disability. J Child Neurol 2013; 28:857-62. [PMID: 22914375 DOI: 10.1177/0883073812452788] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The purpose of this retrospective study was to compare headache etiology, type, and burden and the learning and behavioral profile in children with early-onset (under 6 years) and late-onset (8-12 years) headaches. The study included 133 patients, 35 in the early-onset group and 98 in the late-onset group. Headache diagnosis was based on International Classification of Headache Disorders -II (ICHD-II) criteria. Learning profile and behavioral problems were assessed by parental reports. Tension headache was the most common diagnosis in the early-onset headache group (51.4%). No significant differences were found between the age groups with regard to headache etiology, disability, abnormal neuroimaging results, school performance, or attention problems. Nevertheless, the early-onset group patients had a significantly higher prevalence of behavioral problems: 25.7% versus 11.2% (P < .02). The authors suggest that early age of headache onset does not imply a harmful etiology or a relentless headache disability or burden.
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Affiliation(s)
- Sarit Ravid
- Department of Pediatrics, Meyer Children's Hospital, Rambam Health Care Campus, Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
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Balottin U, Nicoli F, Pitillo G, Ferrari Ginevra O, Borgatti R, Lanzi G. Migraine and tension headache in children under 6 years of age. Eur J Pain 2012; 8:307-14. [PMID: 15207511 DOI: 10.1016/j.ejpain.2003.10.004] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2003] [Accepted: 10/15/2003] [Indexed: 10/26/2022]
Abstract
OBJECTIVE To investigate the clinical features of idiopathic headache with early onset, whose presence is probably underestimated by parents and physicians and the influence of environmental and psychological factors on headache in children. METHODS We report on a prospective longitudinal evaluation of 35 consecutive children referred to the Neuropsychiatry Departments of the Universities of Varese and Pavia (mean age at the first observation: 4 years and 7 months, range: 12 months-6 years; mean age at onset: 4 years and 2 months, range: 10 months-6 years) presenting with headache symptomatology. Mean duration of clinical follow-up: 9.5 months. The diagnosis based on the IHS criteria was then compared to the intuitive clinical diagnosis made in accordance with alternative case definitions. We examined our patients for the presence of early developmental disorders and interictal somatic disorders. We also studied the role of psychosocial factors at the onset and in the course of headache. RESULTS DIAGNOSIS migraine without aura in two cases, episodic tension headache in four cases, migrainous disorders not fulfilling above criteria in eight cases, headache of the tension-type not fulfilling above criteria in 12 cases and headache not classifiable in nine cases. Clinical features of headache are described in the text. Early developmental disorders (0-2 years), such as eating difficulties and sleep disorders, were detected in 18/35 children. Among patients older than 2 years, we also detected interictal somatic disorders (20 cases) such as sleep disorders, eating difficulties, enuresis and idiopathic vomiting. In 14/35 subjects, we identified psychosocial components playing a significant role at the onset of, and during, the headache. CONCLUSIONS A better clinical definition of the disorder would make it easier to identify very young affected children and consequently to plan more specific therapeutic interventions, taking into account environmental and psychological factors. A diagnosis of idiopathic headache becomes particularly significant: according to our cases, despite their being limited in number, migraine and tension headache can be considered also as indices of individual or family related problems requiring appropriate psychiatric or psychological intervention. This stresses the need for a multidisciplinary team of specialists that would include a psychologist/ psychiatrist or headache specialist with specific training in psychiatry.
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Affiliation(s)
- Umberto Balottin
- Child Neuropsychiatry Unit, University of Insubria, Macchi Foundation Hospital, Varese 21100, Italy.
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