N e u r o r a d i o l o g y / H e a d a n d N e c k I m a g i n g • B e s t P r a c t i c e s / R ev i ew

Trofimova et al.
Imaging of Nontraumatic Pediatric Headaches

Neuroradiology/Head and Neck Imaging

Best Practices/Review
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FOCUS ON:

Imaging of Children With

Nontraumatic Headaches
Anna Trofimova1 OBJECTIVE. Headache in children is a common symptom and often is worrisome for
Brianna L. Vey 2 clinicians and parents because of the breadth of possible underlying significant abnormalities,
Mark E. Mullins1 including meningitis, brain neoplasms, and intracranial hemorrhage. For this reason, many
David S. Wolf 3 children with headaches undergo neuroimaging. Most neuroimaging studies performed of
Nadja Kadom1,4 children with headaches have normal findings but may lead to significant downstream effects,
including unnecessary exposure to ionizing radiation or sedation, as well as unnecessary cost
Trofimova A, Vey BL, Mullins ME, Wolf DS, to the health care system. In this article, we review the current evidence and discuss the role of
Kadom N neuroimaging in the diagnosis and management of pediatric headaches, with a special focus
on tools that may aid in increasing the rate of positive findings, such as classification systems,
algorithms, and red flag criteria.
CONCLUSION. Many tools exist that can help in improving the appropriateness of neu-
roimaging in pediatric headache. The main issues that remain to be addressed include scien-
tific proof of safety and validity of these tools and clarity regarding the risks, benefits, and
cost-effectiveness of CT versus MRI in various clinical settings and scenarios.

he diagnostic dilemma in the imaging utilization in children with non-

T evaluation of children and ado-

lescents (< 19 years old) with
headache is that most of them do
traumatic headaches?

Background and Importance

not have a significant intracranial lesion, but
a small percentage of significant and even
life-threatening disorders may be manifest
clinically as isolated headache [1, 2] (Fig. 1).
Keywords: appropriateness, child, evidence, headache,
neuroimaging
For this reason, many pediatric patients un-
dergo costly cross-sectional imaging, such as
doi.org/10.2214/AJR.17.18561 CT and MRI [1].
There are several clinical and radiolog-
Received May 31, 2017; accepted after revision
ic evidence-based guidelines, appropriate-
July 24, 2017.
ness criteria, practice parameters, and diag-
1
Department of Radiology and Imaging Sciences, nostic criteria for children with headaches
Emory  University School of Medicine, 201 Dowman Dr, [3–6] that can help identify the patients in
Atlanta, GA 30322. Address correspondence to this population with a higher likelihood of
N. Kadom (nkadom@emory.edu).
a significant underlying cause for headache.
2
Emory University School of Medicine, Atlanta, GA. Some of these guidelines were developed
for headaches in adults and will be men-
tioned if they have not been adapted for use
3
Department of Pediatrics, Division of Child Neurology,
Emory University School of Medicine, Atlanta, GA.
in children and adolescents. If applied con-
4
Department of Radiology, Children’s Healthcare of sistently, such guiding tools can decrease the
Atlanta, Atlanta, GA. inappropriate use of expensive imaging mo-
dalities and increase the ratio of imaging ex-
AJR 2018; 210:1–10 aminations with a significant finding, result-
ing in an increased ratio of benefit over cost
0361–803X/18/2101–1
[1]. The question examined in this article is:
© American Roentgen Ray Society What are the current options for improving
Headaches are a common complaint
among children, with increasing frequency in
adolescence [7]. According to the Agency for
Healthcare Research and Quality, more than
3 million Americans seek emergency care ev-
ery year because of headaches, one-third of
which are attributable to migraines [8].
The spectrum of headaches in children is
very broad and includes primary and second-
ary causes. In most cases, children who pres-
ent with headaches merely require adequate
pain management. In other cases, they re-
quire detection and treatment of underlying
causes, some of which are life threatening or
carry severe morbidity risk, such as brain tu-
mors, viral and bacterial meningitis, or idio-
pathic intracranial hypertension [9–11].
There is a significant economic burden as-
sociated with headaches in children, including
direct costs, such as primary care, specialist,
and emergency department (ED) visits; addi-
tional tests, including neuroimaging; medica-
tions; and indirect costs [8]. In children, head-
ache morbidity can adversely affect school
performance, attendance of extracurricular

AJR:210, January 2018 1


activities, and academic performance [8]. The
effect of headaches on quality of life in chil-
dren and adolescents has been likened to that
of rheumatoid arthritis or cancer [12]. There
are multiple risk factors for headaches in chil-
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dren, including too little physical activity;
regular nicotine, alcohol, or caffeine use; be-
ing overweight; lack of free time; listening to
music; divorce of parents; negative personal
experience; lack of satisfaction; familial dis-
agreements; abuse; bullying; unfair treatment
by a teacher; and high familial expectations
[13]. A correlation between adolescent anxi-
ety disorders and complaints of headaches or
migraines has also been shown [14].
The 2002 American Academy of Neurol-
ogy (AAN) practice parameters state that,
similar to adult patients, routine neuroimag-
ing studies in children with recurrent head-
aches and a normal neurologic examination
are not indicated [15]. Nonetheless, the rate
of patients undergoing neuroimaging for non-
traumatic headaches increased from 11.1% in
1998 to 31% in 2008, whereas the frequency
of significant intracranial disease decreased
from 10.1% to 3.5% [16, 17]. Kan et al. [18]
reported that the frequency of abnormal find-
ings in children with headaches imaged in
the ED was 10%. Interestingly, the length
of stay for pediatric and adult patients with
headaches in the ED is longer for those who
undergo imaging [17, 19]. These practice pa-
rameters represent potential opportunities
to increase the yield of significant abnormal
findings on neuroimaging studies while prac-
ticing evidence-based medicine.
The management of pediatric headache
may differ depending on the clinical context.
For example, a headache in the setting of trau-
ma can be managed according to established
evidence-based guidelines for head trauma
[20–22], which are beyond the scope of this
article. It can also make a difference in man-
agement of patients with headache whether
the patient presents emergently or nonemer-
gently. The tools available to clinicians that
can affect the utilization of cross-sectional
imaging in children with headaches include
diagnostic criteria for various headache types,
clinical signs that indicate increased likeli-
hood for an underlying significant lesion, and
algorithms for the workup of children with
emergent and nonemergent headaches.
Synopsis and Synthesis of Evidence
Methods
We performed a systematic review of arti-
cles regarding pediatric headaches. Articles
2 AJR:210, January 2018
Trofimova et al.
were identified through PubMed searches of
English-language articles published between
January 1995 and December 2017. The fol-
lowing three search strategies were used:
first, (Headache/classification OR Headache/
diagnosis OR Headache/diagnostic imag-
ing OR Headache/statistics and numerical
data) AND (Child AND Child, Preschool
AND Adolescent); second, (headache AND
child OR adolescent OR preschool child)
AND emergency service, hospital; and
third, (headache AND child OR adolescent
OR preschool child) AND clinical decision.
These searches yielded 541 articles. All arti-
cle abstracts were reviewed for relevance by
two reviewers, and irrelevant articles, such
as articles pertaining to treatment of head-
aches, posttraumatic headaches, and case re-
ports that were summarized elsewhere, were
excluded. The analysis was complemented
by targeted literature searches to expand on
topics that had emerged from the systematic
review. A total of 72 articles were included
in this review.
Epidemiology
The frequency of headache changes by pe-
diatric age group and sex. It has been shown
that 29% of children younger than 5 years re-
ported headache within the past 12 months
and that the frequency of headache increases
to 82% in 13-year-old adolescents [23]. An-
other study reported increased frequency
of headaches in postpubertal patients com-
pared with prepubertal children [24]. A sys-
tematic review reported that the frequency
of headaches over periods between 1 month
and lifetime was 58% in children and ado-
lescents [25].
It has been reported that, in children
younger than 12 years, headaches are slight-
ly more common among boys [26, 27]. For
teenagers, most studies report a female pre-
dominance [28].
Headache Classification in Children
The International Classification of Head-
ache Disorders (ICHD) has been developed by
the International Headache Society and is ac-
cepted worldwide for the diagnosis and clas-
sification of headache disorders [3]. The first
edition of the classification was published in
1988 and did not include specific information
regarding headaches in children [29]. Child-
specific criteria were added to the second edi-
tion of the ICHD issued in 2004 [30].
Currently, the 2013 beta version of the
updated third edition of the classification is
available (ICHD-3 beta) [31]. This version
is more evidence based than the previous
two versions, and clinicians are encouraged
to use the most updated edition in their ev-
eryday practice [13]. The ICHD-3 beta clas-
sifies headaches into three main groups:
first, primary headaches; second, secondary
headaches; and third, painful cranial neu-
ropathies, other facial pains, and other head-
aches [31]. Primary headaches are defined as
headache disorders without other underly-
ing cause [13] and include migraine, tension
headaches, trigeminal autonomic cephalgias,
and other primary headache disorders such
as the daily headache [31]. Secondary head-
aches include a wide variety of disorders in
which headaches are a symptom of an under-
lying cause [13]. The ICHD-3 divides all sec-
ondary headaches into seven main groups:
traumatic headaches (head or neck); cranial
or cervical vascular disorders (Fig. 1); non-
vascular intracranial disorders; substance
use or withdrawal; infections; headache or
facial pain attributed to disorder of the cra-
nium, neck, eyes, ears, nose, sinuses, teeth,
mouth, or other facial or cervical structure;
and psychiatric disorder [31].
Cross-sectional imaging plays a crucial
role in the identification of secondary causes
for headaches. As for significant causes, this
refers to headache-related abnormalities that
carry any significant risk of morbidity or
even mortality, such as meningitis, mass le-
sion, or acute intracranial hemorrhage [32].
Of note, meningitis is best evaluated with
lumbar puncture (in patients without con-
traindications), and imaging is reserved for
further evaluation before lumbar puncture in
patients with increased intracranial pressure,
altered sensorium, or focal findings [32].
Overall, headache in childhood is rarely due
to serious intracranial disease, as shown in a
study of 815 children with headaches, which
found that a significant lesion was present in
only three of 815 (0.37%) patients and was
evident clinically without imaging in two of
those three patients [33]. Nonemergent neu-
roimaging findings in children with head-
aches included Chiari I malformation (23%),
sinusitis (21.1%), and, less commonly, arach-
noid cyst (14%) and vascular malformations
(7%) [34]. Of note, sinusitis may be over-
diagnosed at imaging [14], and arachnoid
cysts are more frequently an incidental fin-
ing, although it has been reported that 41%
of arachnoid cysts in children and adults who
were treated surgically presented with head-
aches [35].
 Imaging of Nontraumatic Pediatric Headaches

Red Flags in Childhood Headache
The cornerstone of parental anxiety and
clinicians’ uncertainty about pediatric head-
aches is the possibility of an underlying brain
tumor. Associations between headaches and
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In 1997, a retrospective study of 315 chil-
dren with headaches identified a set of clini-
cal criteria that were each highly predictive
of space-occupying lesions: persistent head-
aches of less than 6 months’ duration, head-
of less than 6 months’ duration; age younger
than 6 years; no family history of migraine
or primary headaches; occipital headache;
change in type of headache; subacute onset
and progressive headache severity; a new-on-
set headache in a child with immunosuppres-

brain tumors have been studied extensively.
In a cohort of 72 children with brain tumors,
88% had headaches for 2 weeks to 2 months
before the physical examination revealed any
other abnormalities [36]. At the same time,
the general frequency of brain disease in
children with headache as the only symptom
is quoted as less than 1% [37]. In 1991, the
Childhood Brain Tumor Consortium Study
analyzed 3276 children with brain tumors
and found that, overall, 62% of children with
brain tumors had headaches [38]. Most com-
monly, headaches were seen with infratento-
rial tumors (70%); supratentorial tumors were
associated with headache in 58% of patients,
and spinal canal tumors were associated with
headache in 34% of patients. In this cohort,
fewer than 1% of those who presented with
headaches had no other recorded symptoms
on clinical examination at the time of diag-
nosis [38]. Another study reported that three
of 709 (0.4%) neurologically normal children
had significant brain abnormalities [39].
aches with abnormal neurologic examina-
tion, persistence of headaches with absence
of a family history of migraine or primary
headache, persistent headaches associated
with substantial confusion, headaches awak-
ening the child from sleep or immediately af-
ter waking up, and family history or medical
history predisposing to CNS lesions [2].
The mnemonic SNOOP (systemic disease,
neurologic symptoms, onset, occipital, and
pattern) for clinical criteria that can serve
as a red flag for underlying significant le-
sions was first introduced by Dodick in 2003
[40] (Table 1). This rule initially was devel-
oped for adults. In 2010, Kabbouche and
Cleves [41] summarized the existing litera-
ture and concluded that children with head-
aches should undergo neuroimaging if they
met one or more of the following criteria:
abnormal findings at neurologic examina-
tion; atypical presentation, including verti-
go, intractable vomiting, or headache wak-
ing the child from sleep; a recent headache
sion; first or worst headache; systemic symp-
toms and signs; and a headache associated
with confusion, mental status changes, or
focal neurologic complaints [41]. These red
flags were eventually adapted to become the
SNOOOPPPPY mnemonic for use in pediat-
ric populations [13, 42] (Table 1). The pedi-
atric red flags include systemic symptoms or
illness (e.g., fever, altered level of conscious-
ness, anticoagulation therapy, pregnancy,
cancer, or HIV infection), neurologic signs
or symptoms (e.g., papilledema, asymmet-
ric cranial nerve function, asymmetric mo-
tor function, abnormal cerebellar function,
new seizure, or focal findings at examina-
tion), onset recently or suddenly (thunderclap
headache), occipital localization of pain, pre-
cipitated by Valsalva maneuver, positional,
progressive, parent (i.e., lack of family histo-
ry), and years (i.e., age < 6 years) [13, 40, 42].
These criteria have not been validated in
pediatric populations, and although authors

TABLE 1: Evolution of Adult Clinical Headache Evaluation Criteria Over Time and Adaptation to the Pediatric Setting
Acronym, Study
Letter SNOOP, Dodick 2003 [40] SNOOP, Nye and Ward 2015 [42] SNOOPPPPY, Gofshteyn and Stephenson 2016 [13]
a Consultation for “a” particular headache
S Systemic symptoms and signs (fever, myalgias, Systemic symptoms: fever, chills, weight Systemic symptoms or illness: fever, altered level of
weight loss) loss, HIV infection, history of cancer consciousness, anticoagulation therapy,
pregnancy, cancer, HIV infection (especially
concerning in new HIV diagnosis, poor control or
compliance, or associated fever)
S Systemic disease (malignancy, AIDS)
N Neurologic symptoms or signs Neurologic signs or symptoms: confusion, Neurologic symptoms or signs: papilledema,
change in mental status, asymmetric asymmetric cranial nerve function, asymmetric
reflexes, or other abnormalities at motor function, abnormal cerebellar function, new
examination seizure, focal findings at examination
O Onset: sudden (thunderclap headache) Onset: acute, sudden, or split-second Onset recently or suddenly (thunderclap headache)
­thunderclap headache
O Onset after age 40 years Older patient: 50 years old with new onset Occipital localization of pain
or progressive headache
P Pattern change: progressive headache with Previous headache history: first headache Pattern: precipitated by Valsalva maneuver
loss of headache-free periods or different (change in attack frequency,
severity, or clinical features)
P Pattern change: change in type of headache Pattern: positional
P Pattern: progressive
P Parents: lack of family history
Y Headache in children < 5 years Years < 6
None Headache worsening under observation
Note—Changes from one version to another are highlighted in bold.

AJR:210, January 2018 3

 Trofimova et al.

Fig. 1—13-year-old girl with arteriovenous

malformation (AVM) who presented to emergency
department with complaints of profound headache
that acutely started previous evening when she got
up from dinner table. She denied trauma or other any
history of illness before this episode. Neurologic
examination did not show signs of focal weakness or
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balance abnormalities. AVM was surgically resected.

Case illustrates clinical scenario of headache
that was not accompanied by abnormal findings
at neurologic examination. Further diagnostic
imaging was indicated because of new acute onset
of symptoms and revealed significant intracranial
abnormality requiring neurosurgical intervention.
A, Axial unenhanced CT image of head shows
hyperdense acute intraparenchymal hemorrhage
in left cerebellar hemisphere (arrow). There was no
significant associated mass effect on fourth ventricle.
B, Axial T2-weighted MR image at level of posterior
fossa shows tangle of vessels in left cerebellum
(arrows), compatible with AVM, with mild surrounding
edema. There is mild effacement of fourth ventricle
but there was no obstructive hydrocephalus.
A B

Fig. 2—16-year-old boy with sinusitis and intracranial

empyema. Patient presented to emergency
department (ED) with complaint of headache that
he described as “it hurts just above my right eye.”
While he was in ED, headache improved after
administration of ibuprofen, and he was discharged
home without additional testing. He presented to ED
again 4 days later with complaints of fever, headache,
A B body aches, malaise, and abdominal cramping with
several episodes of nonbloody nonbilious vomiting.
He described his headache as frontal in location.
He reported no photophobia, dizziness, or visual
complaints, but recently headache had become
severe enough to keep him awake at night. He had
no neck stiffness at physical examination, and there
was no family history of migraine. Neuroimaging
showed signs of acute sinusitis with intracranial
complications. This case illustrates that, during first
presentation to ED, red flags [13] may not have been
present or may not have been be found clinically
without targeted examination.
A, Axial unenhanced CT image of head shows mild
left frontal soft-tissue swelling (arrow) and slightly
decreased density in extraaxial space subjacent to
frontal skull (arrowheads).
B, Axial unenhanced CT image of head in bone
window shows findings of acute sinusitis with
opacification of frontal sinus with air-fluid level (long
arrow) and osseous destructive changes (short
arrow).
C and D, Axial sequential contrast-enhanced CT
images of head show bifrontal extraaxial fluid
collections (arrows) consistent with empyema.
C D

4 AJR:210, January 2018

 Imaging of Nontraumatic Pediatric Headaches
generally agree on many of the included clin-
ical features, there is no consensus on some
of the other features, such as the age below
which children require neuroimaging or par-
ticular headache characteristics (Table 1 and
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Fig. 2). A retrospective study of 1562 pa-
tients with recurrent headaches, which in it-
self is not considered an imaging indication,
found neuroimaging abnormalities in 9.3%
of patients; of these, only 0.71% of findings
(11/1562) represented lesions requiring surgi-
cal excision [43]. The strongest predictor for
a serious intracranial lesion in that study was
an abnormal neurologic examination, and the
authors requested stricter guidelines for use
of neuroimaging in children with headaches
[43]. There were no lesions requiring surgical
excision in patients who underwent neuroim-
aging for a change in their type of headache,
and the authors even suggested removing
this indication for imaging from the pediat-
ric guidelines [43]. Another study found that
three abnormal findings at neurologic ex-
amination—papilledema, reduced conscious
level, and paralysis—had a strong positive
predictive value for underlying significant
pathologic findings and therefore justified
neuroimaging [44]. A retrospective chart
analysis of 409 children found that blurry vi-
sion and ataxia were the only clinical features
that could predict an underlying intracranial
lesion [45]. Another study found that a bilat-
eral headache in children with focal neuro-
logic deficits had the highest odds of having a
secondary headache cause [46].
There is continued debate about whether
occipital location of headache should be con-
sidered as a red flag. In a study of 283 chil-
dren, an occipital location was the third most
common finding after right and left unilat-
eral locations. In 271 of these patients (96%)
with occipital headache, neuroimaging find-
ings were normal; only incidental abnormali-
ties were found in the remaining 12 patients,
and none of these patients required surgical
intervention [47]. Another study prospective-
ly evaluated 1029 patients with headaches,
and 48 of them (4.7%) experienced recurrent
occipital headaches for a mean course of 2.3
years [48]. In this group, brain imaging find-
ings were normal in 46 patients (95.8%), and
incidental nonsignificant findings were found
in two patients. The frequency of occipital
headache was 5% in patients with migraine
and 4.4% in those with nonmigraine head-
aches without any significant cause [48]. A
retrospective study of 356 children referred
to a pediatric neurologic clinic found that pa-
AJR:210, January 2018 5
tients with occipital headaches were more
likely to undergo neuroimaging [49]. Occipi-
tal location of headache was associated with
Chiari I malformation, but no significant as-
sociations were found with elevated intracra-
nial pressure, tumor, benign cyst, or sinusitis
[49]. The authors concluded that neuroimag-
ing in patients with occipital pain without an
otherwise concerning history or abnormal
findings at neurologic examination can be
foregone [49].
One factor that is not currently consid-
ered as a red flag is parental concern. A re-
cent study investigated 449 patients with
headaches who were referred to a neurology
clinic and of whom 72.2% underwent brain
MRI. Of the patients who underwent imag-
ing, 18.2% of the MRI examinations were
performed because of an atypical headache
pattern or presence of neurologic abnormali-
ties, and 81.8% of MRI examinations were
ordered because of parental concerns [50].
Interestingly, the rate of abnormal MRI find-
ings in this study was similar between pa-
tients for whom neuroimaging was indicat-
ed per clinical indications (16.9%) and those
for whom parental concern was the driver for
neuroimaging (21.9%) [50]. Significant brain
abnormalities relevant to headaches were
found in 0.6% of patients who underwent im-
aging because of clinical indications. For pa-
tients who underwent imaging because of pa-
rental concerns, imaging findings were made
as well, but these were not necessarily caus-
ative of headaches (e.g., Chiari I malforma-
tion, arachnoid cysts, demyelinating lesions,
subdural hygroma, fibrous dysplasia, and pi-
neal gland cyst) [50]. The magnitude of im-
aging studies performed because of paren-
tal concern (81.8%) indicates how difficult it
can be for physicians to argue against neuro-
imaging. The fact that findings were made,
regardless of their relevance to the initial
symptoms, may reinforce parental attitudes
in favor of obtaining more tests.
Clinical and Imaging Guidelines
To make an informed decision about the
workup of headaches, clinicians can use di-
agnostic criteria for each type of headache,
as well as evidence-based tools to assess the
risk for an underlying significant lesion and
appropriateness criteria to guide the selec-
tion of imaging modalities [51].
American Academy of Neurology—In
2000, the U.S. Headache Consortium re-
leased clinical guidelines on diagnosis and
management of migraine in adults [15].
The following symptoms were listed as
significantly increasing the odds of finding
a significant abnormality at neuroimaging:
rapidly increasing headache frequency, his-
tory of dizziness or lack of coordination, sub-
jective numbness or tingling, headache caus-
ing awakening from sleep, and history of
headache worsening with Valsalva maneu-
ver [4, 15]. In 2002, the AAN and the Child
Neurology Society released clinical guide-
lines that adapted the U.S. Headache Con-
sortium recommendations to the pediatric
population (ages 3–18 years) with recurrent
headaches not associated with trauma, fever,
or other secondary causes [15]. These 2002
recommendations were based on six studies
conducted between 1980 and 2000 (one class
II and five class III studies) and included a
total of 1275 children with recurrent head-
aches [15]. Almost half (605) of these chil-
dren underwent neuroimaging and neurolog-
ic examination [15]. The analysis found that
lesions requiring surgical treatment were
found in 14 children (2.3%) and all of them
were accompanied by abnormal findings at
neurologic examination [15]. No lesions re-
quiring surgical intervention were found in
patients with normal neurologic examination
findings [15]. Thus, similar to the recommen-
dations in adults, it was suggested that neu-
roimaging is not indicated in children with
recurrent headaches and a normal neurolog-
ic examination [15]. Neuroimaging should be
considered for children with recurrent head-
aches and abnormal neurologic examination
(e.g., focal findings, signs of increased intra-
cranial pressure, or significant alteration of
consciousness), the coexistence of seizures,
or both; recent onset of severe headache;
change in the type of headache; or headaches
with associated neurologic dysfunction [15].
Since 2002, several European countries
have developed clinical guidelines on head-
ache management for adults and children,
most of which have been translated to Eng-
lish [52–54]. Both U.S. guidelines (AAN
2002) and European guidelines [15] have
been rated as having low-to-moderate qual-
ity [55]. It was found that the lack of homo-
geneity among these various guidelines may
affect their applicability in everyday practice
[55]. Another study confirmed that practice
patterns had not changed significantly after
implementation of clinical practice param-
eters [56]. The study reviewed 725 children
with nonacute headache and normal neuro-
logic examination findings who presented to
a clinic during the years 1992, 1996, 2000,
 Trofimova et al.

and 2004 [56]. The study found increased
neuroimaging use ratios, from 2:1 in 1992 to
7:1 in 2004 [56].
Choosing Wisely Campaign—In Novem-
ber 2013, the American Board of Internal
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used for pediatric patients. In a 2008 com-
mentary, Lewis [61] summarized the results
of five studies, and the following features
were found to be more often associated with
life-threatening causes of headache in chil-
dren presenting to the ED: younger age (2–5
Secondary benign headaches are, by far,
the most common presentation in children
(35–63%), followed by primary headaches
(10–25%); secondary life-threatening head-
aches are the least common (4–15%) [9]. The
frequency of all pediatric patients present-

Medicine and American Headache Associa-

tion released the Choosing Wisely Campaign
for headaches [5]. This campaign issued five
recommendations, two of which addressed
neuroimaging: “Don’t perform neuroimaging
studies in patients with stable headaches that
meet criteria for migraine,” and “Don’t per-
form CT imaging for headache when MRI is
available, except in emergency settings” [5].
American College of Radiology Appropri-
ateness Criteria—The American College of
Radiology (ACR) has released Appropriate-
ness Criteria on imaging utilization for head-
aches in adults [57] and children [6]; the 2017
revision is pending as of this writing. The
ACR supports the notion that, for children,
imaging usually is not appropriate in the
clinical setting of chronic or recurrent head-
ache, including migraine, without neurologic
signs or signs of increased intracranial pres-
sure [6]. Furthermore, the ACR criteria state
that, in the acute setting, particularly where
there is concern for acute subarachnoid hem-
orrhage, CT may be the best imaging choice,
whereas for children with signs of increased
intracranial pressure or positive neurologic
signs, MRI may be preferred over CT [6].
Headache in the Emergency Department
The primary role of emergency physicians
in the care of children with headaches is to
identify life-threatening causes quickly and to
adequately assess and treat non–life-threaten-
ing headache conditions to minimize patient
hospital admissions [8]. From this perspec-
tive, primary headaches and secondary be-
nign headaches, such as headaches associat-
ed with upper respiratory tract and other viral
infections, postoperative headaches, and si-
nus disease– and tooth disorder–related head-
aches, can be classified as typically non–life
threatening. Causes of secondary headaches
that carry significant morbidity or could even
be life threatening include brain tumors, men-
ingitis, idiopathic intracranial hypertension,
stroke, subdural empyema, brain abscess, and
shunt malfunction [9, 58, 59].
Imaging guidelines in emergent childhood
headache—In 2008, the American College
of Emergency Physicians released a clinical
policy on the evaluation and management of
adults presenting to the ED with headaches
[60] that specified that it is not intended to be
years), progression of symptoms for less than ing to the ED with headaches was 0.7–2.1%
2 months, an inability to describe the quality [9, 18, 64]. The rate of subsequent hospital
of the pain, occipital location, extreme inten- admission in children presenting to the ED
sity, and abnormal neurologic examination with headaches was reported to be 4.5–29%
with the four signs found most commonly in [9, 64]. It was found that up to 33% of refer-
cases of serious neurologic conditions (papil- rals to the ED for children with headaches
ledema, abnormal eye movements, hemipa- could have been avoided [65, 66].
resis, and ataxia). Other ways to decrease use of neuroim-
The use of algorithms (clinical manage- aging in the emergency department—Per the
ment pathways) for children with acute head- 2002 AAN practice parameters [15], patients
aches (Fig. 3) may be helpful to facilitate with primary headaches without additional
appropriate patient management [62]. For ex- neurologic deficits do not require neuroim-
ample, the algorithm can inform that, in case aging. To determine a diagnosis of primary
of headache after trauma, the patient should headache, the ICDH-3 beta criteria can be
be treated according to a separate pediatric used [31]. A useful mnemonic for the diag-
head trauma algorithm; if there is an isolat- nosis of migraine is POUNDing (pulsatile
ed headache with fever and there is concern quality, duration of 4–72 hours, unilateral
for meningitis, the patient should undergo a location, nausea or vomiting, and disabling
lumbar puncture (if there are no contrain- intensity) [67]. One study assessed whether
dications); if there is an isolated headache sharing of medical records data could de-
without fever, the patient’s history should crease the odds of performing new diagnostic
be further explored for primary headaches neuroimaging [67]. They found that access to
causes, hypertension, stress, or psychologic prior medical records increased the adher-
factors; and in patients without trauma and ence with evidence-based guidelines and de-
with a neurologic finding, imaging should be creased the use of new neuroimaging, but did
performed [32, 62]. not decrease overall cost [67]. Changing cri-
A prospective analysis of 150 children teria for triage assessments or changing the
presenting to the ED with headaches found triage process may improve imaging utiliza-
a significant intracranial abnormality in 18% tion for pediatric headaches. For example, a
of these children and found that children study found that after-hours nurse telephone
with intracranial lesions had other neurolog- triage systems resulted in up to 33% of refer-
ic signs [63]. rals to the ED, including those for headaches,
Fig. 3—Possible Pediatric
headache algorithm headache
based on previously
published algorithms
No
[32, 63]. Posttraumatic Trauma
Yes Trauma
algorithm
headache should lead
into separate algorithm;
febrile status can lead Yes No
to separate algorithms
Febrile Signs of URI or sinus
immunocompromised? meningismus? algorithm
for upper respiratory
infection (URI) or for Yes
meningitis, which would
best be evaluated with Deficits at
No LP
No
lumbar puncture (LP) neurologic
(meningitis)
examination?
in patients without
contraindication. For Yes
nontraumatic headache Yes
and patients without Red flags? Imaging
fever or other red flags, No
underlying diagnosis is
likely primary headache Primary headache
that does not require algorithm
imaging.

6 AJR:210, January 2018

 Imaging of Nontraumatic Pediatric Headaches

being nonessential on the basis of the final
ED diagnosis [65]. Improving primary care
services for patients with headaches could
also contribute to lower rates of patients pre-
senting to the ED with first-time headache
Downloaded from www.ajronline.org by Florida Atlantic Univ on 09/13/17 from IP address 131.91.169.193. Copyright ARRS. For personal use only; all rights reserved
tice, are excluded from consideration for the
appropriateness ratings.
Exposure to ionizing radiation is an im-
portant consideration because of increased
radiosensitivity of certain tissues in children
for children undergoing helical CT, report-
edly needed in only 8.6% of cases, because
of the high speed of the examination acquisi-
tion [75]. The need for anesthesia sedation in
children was reported to be as high as 28%
in an accountable care organization in 2014,

symptoms [68]. For example, a study showed and the long lifetime after exposure [69]. The
that 22% of adult patients with headaches re- average effective dose for a head CT is list- with 72% of all sedations performed for head
ported first to an ED before seeking care in a ed as 2 mSv for adults [70]. A dose simula- imaging [76].
general neurology outpatient clinic; 9% had tion study in children found that the effective A cost-effectiveness analysis from the so-
been admitted to the hospital for headaches. dose for a head CT can be up to four times cietal perspective compared three groups
All of these patients received a diagnosis of higher in neonates than it is in adults [71]. of children by risk for underlying brain tu-
primary headache [68]. Assuming, on the basis of these data points, mor and cost of cross-sectional imaging [1].
that the effective dose of a pediatric head CT The first group were children with low risk
CT Versus MRI scan can be 2–8 mSv, this would still be be- (0.01%) for brain tumor who had chronic non-
Once a determination is made that imag- low the level of concern for a significant risk migraine headaches for longer than 6 months’
ing should be performed, providers need to of fatal cancer, which is reported to be 10– duration; the second group were children
decide which imaging modality is most ap- 100 mSv [69]. An effective dose of 10 mSv with intermediate risk (0.4%) for brain tumor
propriate. The ACR Appropriateness Crite- may be associated with a fatal cancer risk of who had migraine headaches and a normal
ria [6] provide evidence-based guidance for 1 in 2000 cases; by comparison, the natural neurologic examination; the third group were
this decision. Although the ACR Appropri- risk for fatal cancer in the United States is children with high risk (4%) for brain tumor
ateness Criteria currently include informa- 400 in 2000 cases [72]. who had migraine headaches for less than 6
tion on levels of ionizing radiation exposure Access to CT versus MRI can vary widely months’ duration and an abnormal neurologic
for each listed imaging procedure, this fac- across the United States. A study of availabil- examination (Fig. 4). The study found that the
tor is not considered for the appropriateness ity of CT versus MRI in U.S. EDs reported effective strategy was the use of MRI in the
ratings. Similarly, factors such as access to that 94% had around-the-clock access to CT high-risk group, which yielded a cost-effec-
imaging modalities, need for sedation, and but only 39% had such access to MRI [73]. tiveness ratio of $113,800 per quality-of-life
cost, which may play a role in clinical prac- The level of urgency may influence whether years gained, as compared with more than
an imaging workup will be performed with $1 million in the intermediate-risk group [1].
CT or could be accomplished with MRI [74]. The authors found that no imaging modali-
Another factor influencing the access to CT ty was more cost effective than either CT or
versus MRI is that sedation is rarely needed MRI in the low-risk group [1]. A study from
Spain estimated that the economic burden of
migraine was €1076 million [77]. The use of
clinical decision support (CDS) systems has
been shown to yield substantial decreases in
MRI utilization for headache and other com-
mon indications for advanced imaging, and,
in 2017, CMS was already accepting applica-
tions for preliminary qualification for CDS
mechanisms [78, 79].
There are only a few cost-effectiveness
studies from the patient’s perspective. One
study from the United Kingdom tracked 103
patients with primary headaches who were
randomized to be offered imaging versus no
imaging, and of these patients, 44% scored as
being anxious on the Hospital Anxiety and
Depression Scale at baseline [80]. Patients
A B
who underwent imaging evaluation were less
Fig. 4—14-year-old boy with intracranial neoplasm. Patient was referred to neurology department by his
pediatrician for persistent headaches. Patient had started to experience headaches approximately 3 months anxious at the 3-month follow-up, but were
ago, and initially headaches were attributed to migraine. However, recently his headaches had worsened and similarly anxious as they were at baseline
were accompanied by one episode of emesis. Patient did not have history of seizures. He denied any visual by 1 year. Interestingly, the health care cost
symptoms, subjective numbness, or weakness. Mass was seen at MRI. Patient underwent neurosurgical
resection of mass, which was identified as pilocytic astrocytoma at pathologic examination. Case illustrates
for anxious patients who underwent imaging
that brain tumors can present initially with isolated headache with benign characteristics, but may eventually was significantly lower compared with anx-
develop additional symptoms. ious patients who had not undergone a scan.
A, Axial T2-weighted MR image of brain shows large T2-hyperintense pineal region mass (arrow) with dilation This is likely explained by higher utilization
of atrium of right lateral ventricle.
B, Sagittal contrast-enhanced T1-weighted MR image of brain shows vividly enhancing heterogeneous solid of other medical resources in anxious pa-
mass (arrow) centered in pineal region with mass effect on tectum of midbrain. tients who did not undergo imaging [80].

AJR:210, January 2018 7


Outstanding Issues That
Warrant Research
There is a wealth of material that can be
used to develop interventions for improving
the appropriateness of imaging utilization in
Downloaded from www.ajronline.org by Florida Atlantic Univ on 09/13/17 from IP address 131.91.169.193. Copyright ARRS. For personal use only; all rights reserved
pediatric headache. One major issue that re-
mains is that none of the proposed criteria
sets have been validated in larger pediatric
cohorts. Unless the safety as well as the spec-
ificity and sensitivity of workup algorithms
or sets of red flag criteria are known, it may
be difficult to get buy-in from stakeholders
into projects aimed at decreasing imaging
utilization for pediatric headache.
Although it seems intuitive that obtaining
imaging tests could at least have a reassur-
ing effect on families and patients when the
findings are negative, research indicates that
obtaining diagnostic tests makes hardly any
contribution to the level of patient and family
reassurance [81]. Because the implementation
of CDS systems for use in headache will like-
ly become mandatory in the near future and
because new strategies for including patients
in the decision-making process are being de-
veloped, providers need to build communica-
tion skills to help them balance patient expec-
tations with medical evidence [82, 83].
Besides lack of awareness of evidence and
guidelines and responding to patient anxiety,
providers may also order diagnostic tests in-
appropriately because of medicolegal worries
[70, 84]. For example, Randolph W. Evans,
a coauthor of the American Headache Soci-
ety’s Choosing Wisely list, describes in a let-
ter to the editor of JAMA Internal Medicine
a medicolegal reality in which physicians are
protected when they order unnecessary ex-
aminations but are possibly liable when they
miss a significant finding while following a
guideline [85]. Generating data regarding
safety and validity of clinical algorithms and
sets of red flags may help with certain practi-
tioner concerns, but it may not be enough to
achieve a meaningful change in practice.
Another perspective for improving the
cost-to-benefit ratio in pediatric headache
imaging may be to consider either an im-
aging modality that is lower cost than MRI,
such as CT, or to use shorter MRI protocols,
provided they could be reimbursed at a lower
rate [86, 87]. Radiation exposure in children
is cited as an argument to avoid CT, but ex-
posure to ionizing radiation has to be consid-
ered in the context of the exposed body part
(i.e., effective dose), onetime versus cumula-
tive radiation exposure risks, and compara-
tive cancer risk of natural background expo-
8 AJR:210, January 2018
Trofimova et al.
sure. There are downsides and societal cost
associated with MRI, such as longer exami-
nation times and a possible need for sedation,
which can result in cost in the form of longer
leave from school and longer parental leave
from work. In the past, cost-benefit analyses
of pediatric headaches focused on compar-
ing CT and MRI [1]; future analyses should
consider the cost of missing a significant
finding or delaying treatment, including
medicolegal cost, cost of parental anxiety,
cost of radiation exposure cancer risk rela-
tive to background radiation cancer risk, and
the possibility of offering a shorter MRI pro-
tocol at a cheaper rate.
Summary
Considerable challenges remain in the im-
aging of pediatric headache. The high cost of
imaging and large number of normal exami-
nations in patients without red flags are mo-
tivations to implement programs that can in-
crease the rate of positive findings at imaging.
On the other hand, data regarding the safe-
ty and validity of workup algorithms and red
flag criteria remain to be shown scientifically
to increase practitioners’ and families’ confi-
dence in applying them in daily practice.
We have identified several areas for im-
proving the care of children with headaches
at our institution. We promote the use of the
SNOOPPPPY criteria [13] (Table 1) to iden-
tify children with a high likelihood of an un-
derlying pathologic process as the cause of
their headaches. For emergent presentations,
we recommend an initial CT scan, followed
by MRI if there are abnormal findings. For
nonemergent imaging evaluations in likely
secondary headaches, we perform routine
unenhanced MRI; for nonemergent imag-
ing evaluations in likely primary headaches,
we perform either head CT or a screening
5-minute full-brain MRI that is available
on our MRI vendor’s platform [87]. We an-
ticipate that, by 2018, our pediatric hospital
will adopt a CDS system, likely by purchas-
ing a commercial product. In preparation for
the CDS system, we are planning to develop
algorithms for various headache scenarios
(emergent vs nonemergent, febrile vs nonfe-
brile, and sinus headache) through multidis-
ciplinary collaboration at our institution.
References
1. Medina LS, Kuntz KM, Pomeroy S. Children with
headache suspected of having a brain tumor: a
cost-effectiveness analysis of diagnostic strate-
gies. Pediatrics 2001; 108:255–263
2. Medina LS, Pinter JD, Zurakowski D, Davis RG,
Kuban K, Barnes PD. Children with headache:
clinical predictors of surgical space-occupying le-
sions and the role of neuroimaging. Radiology
1997; 202:819–824
3. Olesen J, Steiner T, Bousser MG, et al. Proposals
for new standardized general diagnostic criteria
for the secondary headaches. Cephalalgia 2009;
29:1331–1336
4. Frishberg BM, Rosenberg JH, Matchar DB, et al.
Evidence-based guidelines in the primary care set-
ting: neuroimaging in patients with nonacute head-
ache. American Academy of Neurology website.
tools.aan.com/professionals/practice/pdfs/gl0088.
pdf. Published 2000. Accessed August 21, 2017
5. Loder E, Weizenbaum E, Frishberg B,
­Silberstein S; American Headache Society Choosing
Wisely Task Force. Choosing wisely in headache
medicine: the American Headache Society’s list of
five things physicians and patients should question.
Headache 2013; 53:1651–1659
6. Strain JD. ACR Appropriateness Criteria on
headache: child. J Am Coll Radiol 2007; 4:18–23
7. Scheller JM. The history, epidemiology, and
classification of headaches in childhood. ­Semin
P­ediatr Neurol 1995; 2:102–108
8. Alfonzo MJ, Bechtel K, Babineau S. Management
of headache in the pediatric emergency depart-
ment. Pediatr Emerg Med Pract 2013; 10:1–25
9. Conicella E, Raucci U, Vanacore N, et al. The
child with headache in a pediatric emergency de-
partment. Headache 2008; 48:1005–1011
10. Kabbouche M, Khoury CK. Management of pri-
mary headache in the emergency department and
inpatient headache unit. Semin Pediatr Neurol
2016; 23:40–43
11. Burton LJ, Quinn B, Pratt-Cheney JL, Pourani M.
Headache etiology in a pediatric emergency de-
partment. Pediatr Emerg Care 1997; 13:1–4
12. Powers SW, Patton SR, Hommel KA, Hershey
AD. Quality of life in childhood migraines: clini-
cal impact and comparison to other chronic ill-
nesses. Pediatrics 2003; 112:e1–e5
13. Gofshteyn JS, Stephenson DJ. Diagnosis and man-
agement of childhood headache. Curr Probl
­Pediatr Adolesc Health Care 2016; 46:36–51
14. Ramsawh HJ, Chavira DA, Kanegaye JT, Ancoli-
Israel S, Madati PJ, Stein MB. Screening for adoles-
cent anxiety disorders in a pediatric emergency de-
partment. Pediatr Emerg Care 2012; 28:1041–1047
15. Lewis DW, Ashwal S, Dahl G, et al; Quality Stan-
dards Subcommittee of the American Academy of
Neurology; Practice Committee of the Child Neu-
rology Society. Practice parameter: evaluation of
children and adolescents with recurrent head-
aches—report of the Quality Standards Subcom-
mittee of the American Academy of Neurology
and the Practice Committee of the Child Neurol-
 Imaging of Nontraumatic Pediatric Headaches
ogy Society. Neurology 2002; 59:490–498
16. Larson DB, Johnson LW, Schnell BM, Goske MJ,
Salisbury SR, Forman HP. Rising use of CT in child
visits to the emergency department in the United
States, 1995–2008. Radiology 2011; 259:793–801
Downloaded from www.ajronline.org by Florida Atlantic Univ on 09/13/17 from IP address 131.91.169.193. Copyright ARRS. For personal use only; all rights reserved
17. Gilbert JW, Johnson KM, Larkin GL, Moore CL.
Atraumatic headache in US emergency depart-
ments: recent trends in CT/MRI utilization and
factors associated with severe intracranial pathol-
ogy. Emerg Med J 2012; 29:576–581
18. Kan L, Nagelberg J, Maytal J. Headaches in a pe-
diatric emergency department: etiology, imaging,
and treatment. Headache 2000; 40:25–29
19. Kanzaria HK, Probst MA, Ponce NA, Hsia RY.
The association between advanced diagnostic im-
aging and ED length of stay. Am J Emerg Med
2014; 32:1253–1258
20. Kuppermann N, Holmes JF, Dayan PS, et al; Pediat-
ric Emergency Care Applied Research Network
(PECARN). Identification of children at very low
risk of clinically-important brain injuries after head
trauma: a prospective cohort study. Lancet 2009;
374:1160–1170 [Erratum in Lancet 2014; 383:308]
21. Osmond MH, Klassen TP, Wells GA, et al; Pediatric
Emergency Research Canada (PERC) Head Injury
Study Group. CATCH: a clinical decision rule for
the use of computed tomography in children with
minor head injury. CMAJ 2010; 182:341–348
22. Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor
J, Mackway-Jones K; Children’s Head Injury Al-
gorithm for the Prediction of Important Clinical
Events Study Group. Derivation of the children’s
head injury algorithm for the prediction of impor-
tant clinical events decision rule for head injury in
children. Arch Dis Child 2006; 91:885–891
23. Scheller JM. The history, epidemiology, and clas-
sification of headaches in childhood. Semin
­Pediatr Neurol 1995; 2:102–108
24. Lateef TM, Grewal M, McClintock W, ­Chamberlain
J, Kaulas H, Nelson KB. Headache in young chil-
dren in the emergency department: use of computed
tomography. Pediatrics 2009; 124:e12–e17
25. Abu-Arafeh I, Razak S, Sivaraman B, Graham C.
Prevalence of headache and migraine in children
and adolescents: a systematic review of popula-
tion-based studies. Dev Med Child Neurol 2010;
52:1088–1097
26. Caperell K, Pitetti R. Seasonal variation of presen-
tation for headache in a pediatric emergency de-
partment. Pediatr Emerg Care 2014; 30:174–176
27. Blume HK. Pediatric headache: a review. Pediatr
Rev 2012; 33:562–576
28. Sillanpaa M. Headache in children. In: Olessen J,
ed. Headache classification and epidemiology.
New York, NY: Raven Press, 1994:273–281
29. Headache Classification Committee of the Interna-
tional Headache Society. Classification and diagnos-
tic criteria for headache disorders, cranial neuralgias
AJR:210, January 2018 9
and facial pain. Cephalalgia 1988; 8(suppl 7):1–96
30. Headache Classification Committee of the Inter-
national Headache Society. The International
Classification of Headache Disorders, 2nd edition.
Cephalalgia 2004; 24(suppl 1):9–160
31. Olesen J. ICHD-3 beta is published: use it imme-
diately. Cephalalgia 2013; 33:627–628
32. Nallasamy K, Singhi SC, Singhi P. Approach to
headache in emergency department. Indian J
­Pediatr 2012; 79:376–380
33. Abu-Arafeh I, Macleod S. Serious neurological
disorders in children with chronic headache. Arch
Dis Child 2005; 90:937–940
34. Alexiou GA, Argyropoulou MI. Neuroimaging in
childhood headache: a systematic review. Pediatr
Radiol 2013; 43:777–784
35. Pradilla G, Jallo G. Arachnoid cysts: case series
and review of the literature. Neurosurg Focus
2007; 22:E7
36. Honig PJ, Charney EB. Children with brain tumor
headaches: distinguishing features. Am J Dis
Child 1982; 136:121–124
37. DeVries A, Young PC, Wall E, et al. CT scan uti-
lization patterns in pediatric patients with recur-
rent headache. Pediatrics 2013; 132:e1–e8
38. The Childhood Brain Tumor Consortium. The
epidemiology of headache among children with
brain tumor. J Neurooncol 1991; 10:31–46
39. Ahmed MA, Martinez A, Cahill D, Chong K,
Whitehouse WP. When to image neurologically
normal children with headaches: development of a
decision rule. Acta Paediatr 2010; 99:940–943
40. Dodick DW. Diagnosing headache: clinical clues
and clinical rules. Adv Stud Med 2003; 3:87–92
41. Kabbouche MA, Cleves C. Evaluation and man-
agement of children and adolescents presenting
with an acute setting. Semin Pediatr Neurol 2010;
17:105–108
42. Nye BL, Ward TN. Clinic and emergency room
evaluation and testing of headache. Headache
2015; 55:1301–1308
43. Rho YI, Chung HJ, Suh ES, et al. The role of neu-
roimaging in children and adolescents with recur-
rent headaches: multicenter study. Headache
2011; 51:403–408
44. Sobri M, Lamont AC, Alias NA, Win MN. Red
flags in patients presenting with headache: clinical
indications for neuroimaging. Br J Radiol 2003;
76:532–535
45. Hsiao HJ, Huang JL, Hsia SH, Lin JJ, Huang IA,
Wu CT. Headache in the pediatric emergency ser-
vice: a medical center experience. Pediatr Neona-
tol 2014; 55:208–212
46. Massano D, Julliand S, Kanagarajah L, et al.
Headache with focal neurologic signs in children
at the emergency department. J Pediatr 2014;
165:376–382
47. Ahmed M, Grossman S, Rafique B, Momoh
Ojewuyi A. Site locked headaches in paediatric
patients do not require routine brain imaging and
rarely have a serious aetiology. Acta Paediatr
2017; 106:791–795
48. Whitehouse A, Momoh-Ojewuyi A, Abusamara
R, Al-Ani S, Alkilani R. Occipital locked head-
ache. J Headache Pain 2013; 14(suppl 1):181
49. Bear JJ, Gelfand AA, Goadsby PJ, Bass N.
Occipital headaches and neuroimaging in chil-
dren. Neurology 2017; 89:469–474
50. Yılmaz Ü, Çeleğen M, Yılmaz TS, Gürçınar M,
Ünalp A. Childhood headaches and brain mag-
netic resonance imaging findings. Eur J Paediatr
Neurol 2014; 18:163–170
51. Silberstein SD. Practice parameter: evidence-
based guidelines for migraine headache (an evi-
dence-based review)—report of the Quality Stan-
dards Subcommittee of the American Academy of
Neurology. Neurology 2000; 55:754–762
52. Géraud G, Lantéri-Minet M, Lucas C, Valade D;
French Society for the Study of Migraine Head-
ache (SFEMC). French guidelines for the diagno-
sis and management of migraine in adults and
children. Clin Ther 2004; 26:1305–1318
53. Bendtsen L, Birk S, Kasch H, et al.; Danish Head-
ache Society. Reference programme: diagnosis
and treatment of headache disorders and facial
pain. Danish Headache Society, 2nd edition, 2012.
J Headache Pain 2012; 13(suppl 1):S1–S9
54. National Institute for Health and Care Excellence
(NICE). Headaches in over 12s: diagnosis and
management. NICE website. www.nice.org.uk/
guidance/cg150. Published September 2012. Up-
dated November 2015. Accessed May 24, 2017
55. Parisi P, Vanacore N, Belcastro V, et al.; Pediatric
Headache Commission of Società Italiana di Neuro-
logia Pediatrica (SINP). Clinical guidelines in pediat-
ric headache: evaluation of quality using the AGREE
II instrument. J Headache Pain 2014; 15:57
56. Graf WD, Kayyali HR, Alexander JJ, Simon SD,
Morriss MC. Neuroimaging-use trends in nonacute
pediatric headache before and after clinical practice
parameters. Pediatrics 2008; 122:e1001–e1005
57. Douglas AC, Wippold FJ 2nd, Broderick DF, et al.
ACR Appropriateness Criteria: headache. J Am
Coll Radiol 2014; 11:657–667
58. Calder K, Kokorowski P, Tran T, Henderson S.
Emergency department presentation of pediatric
stroke. Pediatr Emerg Care 2003; 19:320–328
59. Dunn B, McCalla C, Hiestand B, O’Brien MC.
The pediatric headache that would not go away.
Pediatr Emerg Care 2013; 29:1283–1286
60. Edlow JA, Panagos PD, Godwin SA, Thomas TL,
Decker WW. Clinical policy: critical issues in the
evaluation and management of adult patients pre-
senting to the emergency department with acute
headache. Ann Emerg Med 2008; 52:407–436
61. Lewis DW. Red flags in children who present with

headache: how to recognize a serious problem.
Nat Clin Pract Neurol 2008; 4:412–413
62. Schobitz E, Qureshi F, Lewis D. Pediatric head-
aches in the emergency department. Curr Pain
Headache Rep 2006; 10:391–396
Downloaded from www.ajronline.org by Florida Atlantic Univ on 09/13/17 from IP address 131.91.169.193. Copyright ARRS. For personal use only; all rights reserved
63. Lewis DW, Qureshi F. Acute headache in children
and adolescents presenting to the emergency de-
partment. Headache 2000; 40:200–203
64. Kedia S, Ginde AA, Grubenhoff JA, Kempe A,
Hershey AD, Powers SW. Monthly variation of
United States pediatric headache emergency de-
partment visits. Cephalalgia 2014; 34:473–478
65. Doctor K, Correa K, Olympia RP. Evaluation of
an after-hours call center: are pediatric patients
appropriately referred to the emergency depart-
ment? Pediatr Emerg Care 2014; 30:798–804
66. Detsky ME, McDonald DR, Baerlocher MO,
Tomlinson GA, McCrory DC, Booth CM. Does
this patient with headache have a migraine or need
neuroimaging? JAMA 2006; 296:1274–1283
67. Bailey JE, Wan JY, Mabry LM, et al. Does health
information exchange reduce unnecessary neuro-
imaging and improve quality of headache care in
the emergency department? J Gen Intern Med
2013; 28:176–183
68. Gahir KK, Larner AJ. Primary headache disorder
in the emergency department: perspective from a
general neurology outpatient clinic. Emerg Med J
2006; 23:135–136
69. Frush DP, Donnelly LF, Rosen NS. Com-
puted tomography and radiation risks: what pedi-
atric health care providers should know. P
­ ediatrics
2003; 112:951–957
70. McCollough CH, Bushberg JT, Fletcher JG, Eckel
10 AJR:210, January 2018
Trofimova et al.
LJ. Answers to common questions about the use
and safety of CT scans. Mayo Clin Proc 2015;
90:1380–1392
71. Huda W, Vance A. Patient radiation doses from
adult and pediatric CT. AJR 2007; 188:540–546
72. U.S. Food and Drug Administration (FDA). What
are the radiation risks from CT? FDA website.
www.fda.gov/radiation-emittingproducts/­radiation​
emitting​products​and​procedures/medicalimaging/
medicalx-rays/ucm115329.htm. Updated February
27, 2017. Accessed July 6, 2017
73. Ginde AA, Foianini A, Renner DM, Valley M,
Camargo CA Jr. Availability and quality of com-
puted tomography and magnetic resonance imag-
ing equipment in U.S. emergency departments.
Acad Emerg Med 2008; 15:780–783
74. Calder K, Kokorowski P, Tran T, ­Henderson
S. Emergency department presentation of pediatric
stroke. Pediatr Emerg Care 2003; 19:320–328
75. Sacchetti A, Carraccio C, Giardino A, Harris RH.
Sedation for pediatric CT scanning: is radiology
becoming a drug-free zone? Pediatr Emerg Care
2005; 21:295–297
76. Uffman JC, Tumin D, Raman V, Thung A,
Adler B, Tobias JD. MRI utilization and the asso-
ciated use of sedation and anesthesia in a pediatric
ACO. J Am Coll Radiol 2017; 14:924–930
77. Badia X, Magaz S, Gutiérrez L, Galván J. The bur-
den of migraine in Spain. Pharmacoeconomics
2004; 22:591–603
78. Blackmore CC, Mecklenburg RS, Kaplan GS. Ef-
fectiveness of clinical decision support in control-
ling inappropriate imaging. J Am Coll Radiol
2011; 8:19–25
79. Centers for Medicare & Medicaid Services (CMS).
Clinical decision support mechanisms. www.cms.​
gov/Medicare/Quality-Initiatives-Patient-­Assessment-
Instruments/Appropriate-Use-Criteria-Program/
CDSM.html. Accessed July 6, 2017
80. Howard L, Wessely S, Leese M, et al. Are investi-
gations anxiolytic or anxiogenic? A randomised
controlled trial of neuroimaging to provide reas-
surance in chronic daily headache. J Neurol
­Neurosurg Psychiatry 2005; 76:1558–1564
81. van Ravesteijn H, van Dijk I, Darmon D, et
al. The reassuring value of diagnostic tests: a sys-
tematic review. Patient Educ Couns 2012; 86:3–8
82. Verbeek J, Sengers MJ, Riemens L, H ­aafkens
J. Patient expectations of treatment for back pain: a
systematic review of qualitative and quantitative
studies. Spine (Phila Pa 1976) 2004; 29:2309–2318
83. Schers H, Wensing M, Huijsmans Z, van Tulder
M, Grol R. Implementation barriers for general
practice guidelines on low back pain a qualitative
study. Spine 2001; 26:E348–E353
84. Brown SR, Brown J. Why do physicians order un-
necessary preoperative tests? A qualitative study.
Fam Med 2011; 43:338–343
85. Evans RW. Headaches and neuroimaging. JAMA
Intern Med 2015; 175:312
86. Sharma A, Reis M, Parsons MS, et al. Two-tiered
approach to MRI for headache: a cost-effective
way to use an expensive technology. AJR 2013;
201:[web]W75–W80
87. Prakkamakul S, Witzel T, Huang S, et al. Ultrafast
brain MRI: clinical deployment and comparison
to conventional brain MRI at 3T. J Neuroimaging
2016; 26:503–510