The value of CT scans for children with headaches

Rates of Presentation, Treatments and Serious Neurologic Disorders Among Children and Young Adults Presenting to US Emergency Departments With Headache

OBJECTIVE

To evaluate rates of presentation, neuroimaging, therapies, and serious neurologic disorders (SNDs) among children and young adults presenting to the emergency department with headache.

METHODS

We performed a cross-sectional study of a nationally representative sample survey of visits to US emergency departments between 2002 and 2017. We identified encounters of patients ≤25 years old with chief complaint of headache. We report the rates of presentation, imaging, and treatments and report proportions having concomitant diagnoses of serious neurologic disorders.

RESULTS

Among encounters ≤25 years, 2.0% had a chief complaint of headache, with no change in the yearly rates of encounters (P = .98). Overall, 20.8% had a head computed tomography (CT), with a reduction in performance between 2007 and 2016 (P < .01). One-quarter (25.2%, 95% confidence interval [CI] 22.2%-28.3%) were given narcotics and 2.5% (95% CI 1.7%-3.2%) had serious neurologic disorders.

CONCLUSION

Overall, 2.0% of emergency department encounters among patients ≤25 years were for headache, with low rates of serious neurologic disorders. CT use appeared to be declining.

Occipital Headaches and Neuroimaging in Children

PURPOSE OF REVIEW

The goal of this review is to outline the prevalence and significance of occipital headaches in children and how they relate to neuroimaging findings. We seek to evaluate the concern that occipital headaches in children are indicative of secondary headache pathology by reviewing the yield of neuroimaging in pediatric patients with occipital headache location.

RECENT FINDINGS

Occipital headaches are a common presentation of primary headache disorders in children, seen in 7-16% of children presenting for evaluation of headache and in up to 20% of children diagnosed with migraine in the emergency department. Review of recent literature confirms that in and of itself, occipital location of headache in a child with recurrent headache and a normal physical examination should not be regarded as worrisome. Headaches with associated signs on neurologic examination should be investigated for a secondary cause, regardless of headache location. Occipital headaches that do not meet criteria for a primary headache disorder should be evaluated for site-specific occipital headache conditions. Neuroimaging for recurrent headache in children who have normal neurological examinations has an overall low yield (0-4.1%) for actionable findings in recent studies. Importantly, an abnormal neurologic examination often predicts the presence of neuroimaging abnormalities. In the absence of an atypical history or abnormalities on clinical examination, occipital headaches in children are no more likely to be associated with intracranial pathology than headaches in other locations. If the child's headaches are otherwise consistent with migraine or another primary headache disorder, and the neurologic examination is normal, the yield of neuroimaging is low, and imaging can generally be deferred.

Site locked headaches in paediatric patients do not require routine brain imaging and rarely have a serious aetiology

AIM

The main aim of this study was to examine the aetiology and the yield of brain imaging of children with site locked headaches (SLH).

METHODS

This study was carried out at Queen's University Hospital, Essex, UK, from August 2011 to August 2015 and focused on patients who were at least five years of age, had experienced at least five SLH attacks and had a normal neurological examination. Bilateral or alternating unilateral headaches were excluded. Data were collected prospectively, and the headache diagnosis was based on the International Classification of Headache Disorders.

RESULTS

We identified 292 eligible patients (60% female) aged 5.1-17 years: 177 with unilateral SLH, 104 with occipital SLH and 11 with vertex SLH. Anterior headaches were the most frequent (n = 133), and the diagnoses included migraine (n = 192), tension type headaches (n = 30) and medication-overuse headaches (n = 22). The headache was unspecified in 43 cases. Magnetic resonance imaging was normal in 96% of the 283/292 scanned or showed a nonspecific, nonsignificant abnormality in 4%.

CONCLUSION

Site locked headaches were most likely to be caused by primary headaches, particularly migraine. An SLH without abnormal neurological findings is unlikely to have an underlying sinister aetiology, and routine brain imaging is not required in such cases.

Neuroimaging in childhood headache: a systematic review

Headache is a common complaint in children, one that gives rise to considerable parental concern and fear of the presence of a space-occupying lesion. The evaluation and diagnosis of headache is very challenging for paediatricians, and neuroimaging by means of CT or MRI is often requested as part of the investigation. CT exposes children to radiation, while MRI is costly and sometimes requires sedation or general anaesthesia, especially in children younger than 6 years. This review of the literature on the value of neuroimaging in children with headache showed that the rate of pathological findings is generally low. Imaging findings that led to a change in patient management were in almost all cases reported in children with abnormal signs on neurological examination. Neuroimaging should be limited to children with a suspicious clinical history, abnormal neurological findings or other physical signs suggestive of intracranial pathology. Well-designed prospective studies are needed to better define the clinical findings that warrant neuroimaging in children with headache.

The evaluation and management of paediatric headaches

The management of patients with headaches is a major component of every paediatric practice. In a nationally representative sample of Canadian adolescents, it was found that 26.6% of those 12 to 13 years of age and 31.2% of those 14 to 15 years of age reported that they experienced headaches at least once per week.The diagnosis of headaches in children and adolescents is established through a headache history in the vast majority of patients. Specific questions can identify those at most risk for headaches secondary to underlying pathology. Similarly, the examination should be tailored to identify those who require further investigation. Investigations are not routinely indicated for paediatric headache, but neuroimaging should be considered in children whose headaches do not meet the criteria for one of the primary headache syndromes and in those with an abnormal neurological examination.The optimal treatment of primary headaches should begin with nonpharmacological methods. Preventive pharmacological therapy should be considered when headaches significantly impair the patient's quality of life. Flunarizine may be valuable in paediatric headache prevention, and ibuprofen, acetaminophen and nasal sumatriptan may be effective in the acute management of headaches.

The role of neuroimaging in children and adolescents with recurrent headaches--multicenter study

OBJECTIVES

To evaluate the role of neuroimaging and to estimate the prevalence of significant and treatable intracranial lesions in children and adolescents with recurrent headaches.

BACKGROUND

Neuroimaging studies are commonly performed in children and adolescent patients with headache because of increasing demands by parents and physicians, although objective data and studies to support this widespread practice are minimal.

METHODS

We retrospectively reviewed the medical records of all 1562 (male 724, female 838) new patients presenting with recurrent headaches to 9 Pediatric Neurology Clinics of tertiary Hospitals. Data regarding age of onset, duration of symptoms before presentation, frequency, duration of each episode, intensity, location and quality of headache, associated neurologic symptoms and a comprehensive neurological examination were obtained for each patient. The International Classification of Headache Disorders, second edition, was used to classify headache types.

RESULTS

Neuroimaging procedures were performed in 77.1% of the patients. Overall, 9.3% (112/1204) of the patients had abnormal findings from neuroimaging. The highest yield was in patients with an abnormal neurological examination wherein abnormal findings on neuroimaging were seen in 50.0% (9/18) of patients (P < .001). The yield was low when imaging was carried out in view of changes in the type of headache (12.9% [26/201]), neurologic dysfunction (10.8% [9/83]), recent onset of severe headaches (7.0% [12/171]), and demands of parent and physicians (10.1% [21/208]). Eleven patients underwent surgery based on neuroimaging results. There was no significant relation between abnormality on neuroimaging and age, sex, headache type, age of onset of headache, duration of symptoms before presentation, duration, frequency, location and intensity of headache (P > .05).

CONCLUSIONS

Neuroimaging procedures in children and adolescents with headaches, although not always required, are very commonly performed. We suggest that more strict guidelines for rational use of neuroimaging are needed for pediatric headache patients.

Incidental neuroimaging findings in nonacute headache

We studied the frequency and consequences of incidental neuroimaging findings in 400 otherwise healthy, nonacute pediatric headache patients through a retrospective, cross-sectional analysis. We excluded patients with currently recommended clinical criteria to consider diagnostic neuroimaging. We categorized neuroimaging results as normal, remarkable without clinical action, remarkable with clinical follow-up action, and abnormal. One hundred eighty-five of 400 patients (46%) had neuroimaging. Of these, 78.4% of neuroimaging studies were normal, and none was considered abnormal. Also, 21.5% had remarkable findings in the neuroradiology report. The frequency and types of all incidental findings were generally comparable to previous studies. One third of these patients received further consultation or neuroimaging because of incidental findings. In the evaluation of nonacute pediatric headache, overuse of neuroimaging leads to frequent discovery of incidental findings and increased testing. Individualized health care calls for physician-consumer discussions about current indications for neuroimaging, the general frequency of incidental findings, and potential difficulties in their interpretation.

Diagnostic testing for migraine and other primary headaches

Most primary headaches can be diagnosed using the history and examination. Judicious use of neuroimaging and other testing, however, is indicated to distinguish primary headaches from the many secondary causes that may share similar features. This article evaluates the reasons for diagnostic testing and the use of neuroimaging, electroencephalography, lumbar puncture, and blood testing. The use of diagnostic testing in adults and children who have headaches and a normal neurologic examination, migraine, trigeminal autonomic cephalalgias, hemicrania continua, and new daily persistent headache are reviewed.

Headache in young children in the emergency department: use of computed tomography

OBJECTIVE

The goal was to determine whether computed tomographic (CT) scans led to better acute care of young children with headache presenting the emergency department (ED).

METHODS

We examined the records of 364 children 2 to 5 years of age who presented with headache to a large urban ED between July 1, 2003, and June 30, 2006. By reviewing initial history and examination findings, we first identified patients with secondary headaches (ie, with readily identifiable explanations such as ventriculoperitoneal shunts, known brain tumors, or acute illnesses, such as viral syndromes, fever, probable meningitis, or trauma). Charts for the remaining patients were reviewed for headache history, neurologic examination findings, laboratory and neuroimaging results, final diagnosis, and disposition.

RESULTS

On the basis of initial history and physical examination results, 306 children (84%) had secondary headaches. For 72% of those children, acute febrile illnesses and viral respiratory syndromes accounted for the headaches. Among the 58 children (16%) who had no recognized central nervous system disease or systemic illness at presentation, 28% had CT scans performed. Of those, 1 scan yielded abnormal results, showing a brainstem glioma; the patient demonstrated abnormal neurologic examination findings on the day of presentation. For 15 (94%) of 16 patients, the CT scans did not contribute to diagnosis or management. For 59% of children with apparently primary headaches, no family history was recorded.

CONCLUSION

For young children presenting to the ED with headache but normal neurologic examination findings and nonworrying history, CT scans seldom lead to diagnosis or contribute to immediate management.

Neuroimaging-use trends in nonacute pediatric headache before and after clinical practice parameters

OBJECTIVES

The objective of this study was to determine trends in diagnostic neuroimaging-use rates in nonacute pediatric headache before and after publication of clinical practice guidelines.

METHODS

Retrospective, cross-sectional analysis was conducted of neuroimaging rates for 725 children and adolescents who were aged 3 to 18 years with nonacute headache and normal neurologic examination and were evaluated in a single pediatric neurology clinic during study years 1992, 1996, 2000, and 2004. Following recommendations of current practice parameters, patients with conditions that justify consideration for neuroimaging (eg, progressive headache, abnormal neurologic examination) were excluded from this analysis. We recorded the origin of any neuroimaging request at the time of the clinic visit and any abnormal neuroimaging findings that led to major clinical consequences.

RESULTS

Overall, the mean rate of neuroimaging for patients with nonacute headache was 45%. Use rates remained steady during the 13-year study period (range: 41%-47%). The majority of neuroimaging studies were ordered originally by primary care providers. The proportion of neuroimaging studies that were ordered by primary care providers increased significantly from 1992 to 2004.

CONCLUSIONS

In the evaluation of patients who had nonacute pediatric headache and were referred to a child neurology clinic, neuroimaging-use rates remained stable during the past decade. An increasing proportion of neuroimaging studies are ordered by primary care providers. The influence of evidence-based medicine on medical decision-making may be partly responsible for curbing increases in neuroimaging overuse. The perceived value of neuroimaging by physicians and consumers deserves ongoing study.

ACR Appropriateness Criteria on headache-child

In a pediatric patient with an isolated headache or a classic migraine unaccompanied by neurologic signs, presence of a seizure, or supporting historical data, an imaging workup is usually not indicated. For a sudden severe headache or a headache with positive neurologic signs or symptoms or supporting historical data, MRI or CT should be considered. For the acute severe (thunderclap) headache, CTA, MRA, or catheter angiography may be appropriate.

Headaches in the pediatric population

Headaches are an extremely common complaint encountered in the pediatric population. The headache history establishes the diagnosis in the vast majority and most importantly identifies features suggesting a secondary cause. The headache history outlined will aid in headache classification and screen for ominous causes. A comprehensive headache examination is aimed at excluding secondary causes. Headaches resulting from serious organic causes are virtually always associated with neurologic signs at the time of presentation. Investigations are not routinely required for pediatric headache, but neuroimaging should be strongly considered in children with an abnormal neurologic examination or history worrisome for intracranial pathology. The management approach for children with primary headaches should focus on reassurance and education. Developing an individualized therapeutic strategy requires knowledge of the child's headache-related disability and impact on quality of life. Treatment should begin with a nonpharmacologic approach, which influences lifelong prevention and management of headaches. Pharmacologic interventions target both acute symptomatic treatment and prophylactic medications. Preventative treatment may be beneficial when headaches result in significant disability and impaired quality of life. The limited available evidence for prophylactic treatment options is reviewed. Research into pediatric headache prevention and management remains a priority given the potential lifelong morbidity associated with headache.

Headaches in children and adolescents: update 2001

It is now recognized that headaches are frequent in children and even more common in adolescents. In this article, the recent significant changes that have taken place in the classification, epidemiology, evaluation, and treatment of headaches in children and adolescents are reviewed.

The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurological examinations

OBJECTIVES

To assess the utility of neuroimaging in the evaluation of children presenting with two of the most common forms of headache, migraine and chronic daily headache, and to determine the utility and pathological yield of neuroimaging in specific headache syndromes in children whose neurological examinations are normal.

METHODS

We retrospectively reviewed the medical records of patients coded for headache (ICD 784) in the Pediatric Neurology Clinic at Children's Hospital of the King's Daughters between 1997 and 1999. The age range considered was between 6 and 18 years. The study focused on the two most common types of headache, uncomplicated migraine and chronic daily headache. Only patients with normal physical and neurological examinations were considered in this analysis.

RESULTS

Three hundred two patients were coded for headache within the defined age group. One hundred seven (35.4%) patients fulfilled IHS-R criteria as having uncomplicated migraine with a normal examination, and 30 (9.9%) patients fulfilled criteria for chronic daily headache. Twenty-nine (9.6%) patients presented with migrainelike symptoms, and 6 (2.0%) presented with chronic daily symptoms, but had neurological abnormalities present on examination. The remainder of the patients with headache had the following etiologies: 50 (16.6%) with secondary headache, 22 (7.3%) with complicated migraine, 20 (6.6%) with posttraumatic headache, 13 (4.3%) with seizure-related headache, 11 (3.6%) with brain tumors, 10 (3.3%) with tension-type headache, and 4 (1.3%) with pseudotumor cerebri. Of the 107 patients with migraine, 42 (39.3%) received CT scans; 2 (4.8%) of which were considered "abnormal." One of the abnormalities was an arachnoid cyst and the other was a dilated Virchow-Robin space. Twelve (11.2%) patients with migraine received an MRI, 2 (16.7%) of which were considered abnormal. Both of the abnormal findings were Chiari type I malformations. Of the 30 patients with chronic daily headache, 17 (56.7%) received CT scans, 3 (17.6%) of which were considered abnormal. The abnormalities consisted of a maxillary opacification, a mucous retention cyst, and an occult vascular malformation. Eight (26.7%) of the patients with chronic daily headache had an MRI, 2 (25.0%) of which were abnormal. One of the abnormalities was a Chiari I malformation, and the other was an occult vascular malformation.

CONCLUSION

The yield of neuroimaging in children with uncomplicated migraine and normal neurological examination was 3.7%. The yield in children with chronic daily headache and normal neurological examination was higher at 16.6%. The abnormalities discovered included arachnoid cysts, Chiari I malformations, sinus disease, occult vascular malformations and "dilated Virchow-Robin spaces." While none of the neuroimaging findings were apparent clinically, their discovery did not influence the diagnosis, management, or outcome of the patients. None of the abnormalities necessitated surgical intervention or were associated with the headache presentation. Therefore, neuroimaging is not warranted in children and adolescents with defined clinical headache syndrome diagnoses whose neurological examinations are normal.

Headaches in a pediatric emergency department: etiology, imaging, and treatment

OBJECTIVE

To assess the spectrum of diagnoses, the use of CT scans of the brain, and pharmacological treatments in patients presenting to a pediatric emergency department with headaches as the chief complaint.

METHODS

A 1-year retrospective chart review of all children who presented to the emergency department with a headache as the chief complaint.

RESULTS

One hundred thirty patients (0.7% of all pediatric emergency department visits, mean age = 9.3 years) were included in the study. Primary headaches included 11 migraine (8.5%) and 2 tension headaches (1.5%). Most of the secondary nonneurological headaches were associated with viral and respiratory illnesses (n=37, 28.5%), while the majority of the secondary neurological headaches included 26 posttraumatic (20%), 15 possible ventriculoperitoneal shunt malfunctions (11.5%), and 3 cases of aseptic meningitis (2.3%). The neurological etiology in 9 of these children (6.9%) was found to be serious (subdural hematoma, epidural hematoma, proven ventriculoperitoneal shunt malfunction, brain abscess, pseudotumor cerebri, and aseptic meningitis). Fifteen patients could not be etiologically classified, either because no specific etiology was found or their discharge diagnoses could not clearly explain the headache. Approximately 10% (5/53) of the CT scans of the head that were performed showed new abnormal findings including hydrocephalus secondary to ventriculoperitoneal shunt malfunction (2), subdural hematoma (1), epidural hematoma (1), and skull fracture (1). Forty-two patients (32%) were treated pharmacologically. Thirty-nine of the 42 treated patients (93%) were given over-the-counter analgesics, and 9 (21%) were given prescribed analgesics.

CONCLUSIONS

The majority of the headaches in the pediatric emergency department were secondary to concurrent illness and minor head trauma, and required no pharmacological treatment or only treatment with minor analgesics. In a small minority of patients, headaches were secondary to serious neurological conditions, which required immediate medical attention. Computed tomography scans showed new abnormalities in a minority of patients and should be reserved for those with neurological diagnoses such as head trauma and ventriculoperitoneal shunt, as well as for those patients with recent onset of headaches with no clear etiological explanation, and for those with high-risk medical conditions, such as hypocoagulabilities. Future prospective studies are needed to assess the efficacy of the various pharmacological treatments in this population.

The evaluation of headaches in children and adolescents

The importance of a thorough evaluation of each patient with headache is stressed. Details of the data base, pertinent information regarding the physical examination, and thoughts concerning selection of laboratory tests are provided. The majority of headache types seen in pediatric practice can correctly be identified using these methodologies.