Question

• In children and adolescents with chronic headaches, who should have neuroimaging?

Clinical Bottom Lines

1. Neuroimaging is not recommended, or cost-effective, for children with chronic/recurrent headaches and a low risk of brain tumor.

Summary of Key Evidence

1. Retrospective chart review of 133 children (age 3-18 yrs) referred to pediatric neurology clinic for recurrent headache.¹
   
2. Various types of headache: migrainous (52%), chronic tension HA (21%), mixed, post-traumatic, psychogenic, unclassified (19%).
   
3. 78 patients (59%) were imaged with CT, MRI, or both.
   
4. Reasons for imaging: abnormal headache pattern, neurologic abnormalities during headache, constitutional symptoms, parental and/or physician concern.
   
5. 4 patients had cerebral abnormalities found on CT/MRI.
   
6. None of findings required treatment or were believed to contribute to headache presentation.
   
7. Estimated risk of finding significant abnormalities in children with recurrent headaches to be no higher than 3.8%.
   

Additional Comments

• Other studies found similar risk of abnormalities in children with headaches and normal physical and neurologic examination.²
• Most cost effective strategy depends upon the probability of tumor-for low risk children recommended close follow up, for intermediate risk recommended CT followed by MRI for any positive results, for high risk recommend MRI.³
  
• Predictors of space-occupying lesions include: Sleep-related HA, no family history of migraine, no visual symptoms, duration of headache < 6 mo, abnormal neuro exam, vomiting, and confusion.⁴
  

Citation

1. Maytal J, Bienkowski RS, Patel M, Eviatar L. The value of brain imaging in children with headaches. Pediatrics 1995;96:413-416.
   
2. Lewis DW, Dorbad D. The utility of neuroimaging in the evaluation of children with migraine or chronic daily headache who have normal neurologic examinations. Headache 2000;40:629-632.
   
3. Medina S, Kuntz K, Pomeroy S. Children with headache suspected of having a brain tumor: a cost-effectiveness analysis of diagnostic strategies. Pediatrics 2001;108:
   
4. Medina S, Pinter JD, et al. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology 1997;202:819-24.
   

CAT Author: Amy Benzing, MD

CAT Appraisers: Jonathan Fliegel, MD

Date appraised: March 11, 2002