Paediatric, Headache (Recurrent)

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Recurrent Headaches in Children

• Headaches are common in childhood affecting up to 90% of school aged children 1-4
• Upper respiratory tract viral infections, psychosocial problems, migraines and cluster headaches are among the most common causes 1
• Current literature unfortunately lacks well-designed prospective studies evaluating diagnostic tests in children with recurrent headaches 1, 2
• In one meta-analysis, brain tumours were detected in 1.5% of children who had neuroimaging performed. 5 All children who had a treatable surgical cause for their headaches had abnormal findings on neurological exam
• There is also a lack consensus among clinicians regarding the threshold for neuroimaging in a child with recurrent headaches 6

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Computed Tomography (CT)

• Computed tomography offers a widely available, quick and inexpensive imaging modality 1, 3
• It is typically performed in acute situations in which haemorrhage is suspected or for the rapid diagnosis of a space occupying lesion 2
• The main disadvantage is the use of ionising radiation. CT is also inferior to MRI for assessment of the posterior cranial fossa, white matter and sellar lesions 7
• Advantages for CT include its accessibility, absence of need for sedation and low cost 3
• There are few studies which have directly compared the sensitivity of CT and MRI for the investigation of paediatric headache. In one study there was no significant difference between the two for the detection of surgical space occupying lesions 3, 8

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Magnetic Resonance Imaging (MRI)

• MRI is recommended for patients with focal neurology and miscellaneous findings such as vertigo or hemiplegic migraine 1
• If available, MRI is generally preferred for the neuroimaging of children as it does not involve ionising radiation. Compared to CT, it allows for superior visualisation of the posterior cranial fossa, craniocervical junction lesions, white matter and sellar lesions 2, 3
• However, it is more expensive and can be time consuming. Sedation or general anaesthesia is generally necessary in children under 6 years old 3
• In terms of cost-effectiveness, MRI has been shown to be the most effective strategy for children at high risk of serious pathology (abnormal neurological exam or the presence of red flags) 9

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Red Flags

• The following Red Flags may warrant further investigation 2
  • Persistent headaches of less than 6 months duration that does not respond to medical treatment
  • Persistent headaches associated with an absent family history of migraine
  • Persistent headaches associated with substantial episodes of confusion, disorientation, or emesis
  • Headaches that awaken the child repeatedly from sleep or occur immediately on wakening
  • Family or medical history of disorders that may predispose to CNS lesions and clinical or laboratory findings suggestive of CNS involvement
  • Age
• There is sufficient evidence to suggest that the presence of associated neurological signs is a definite indication for imaging. Among children with brain tumours, over 94% had an abnormal neurological exam 10, 11
• The other red flags which may suggest a space occupying lesion were derived from a retrospective study on 315 children with headache. The study found that sleep-related headache and no family history of migraine were the strongest predictors of a space occupying lesion. The features have not however been prospectively validated 8
• Imaging is generally not recommended for children with migraine headaches and a normal neurological exam. However, atypical features or children who do not fulfil the strict definition for migraine may reduce the threshold for imaging 12

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