The Value of Brain Imaging in Children With Headaches

(1)

PEDIATRICS

MI. 3

The

Value

of Brain

Imaging

in Children

With

Headaches

Joseph Maytal, MD; Robert S. Bienkowski, PhD; Mahendra Patel, MD; and Lydia Eviatar, MD

ABSTRACT. Objective. To determine the value of

performing computed tomography (CT) or magnetic

res-onance imaging (MRI) studies in children with chronic

headaches.

Background. Headache is a common complaint in children, With the proliferation of brain imaging centers and the increasing patient demand for CT or MRI stud-ies, brain imaging has become widely used to evaluate headaches.

Methods. A retrospective chart review was conducted

of all children referred to the pediatric neurology clinic for evaluation of headaches over a 2-year period. Charts were reviewed for headache characteristics, clinical mdi-cations for performing CT and MRI studies, and imaging results. Particular attention was paid to evidence of brain tumors, vascular anomalies, or hydrocephalus.

Results. A total of 133 records were studied. Subjects

ranged in age from 3 to 18 years. Most patients were

diagnosed as having either vascular migrainous

head-aches (52%) or chronic tension headaches (21%). Other

headache diagnoses were mixed tension-migraine,

psy-chogenic, and post-traumatic. Headaches were

unclassi-fled in 25 patients (19%). Seventy-eight patients (59%) had brain imaging: 45 had MR!, 27 had CT, and 6 patients

had both. In most cases, brain imaging studies were

performed in patients with atypical headache pattern, presence of neurologic abnormalities during the head-ache, general symptoms (ie, weight loss or fatigue), or because of parents’ or doctors’ concerns about brain

tu-mors. Cerebral abnormalities were found on brain imag-ing in four patients, but none indicated the presence of a

treatable disease and all were deemed unrelated to the

presenting complaint. Our findings of no relevant abnor-malities in a series of 78 brain imaging studies indicate

From the *Divion of Pediatric Neurology and tPediatric Research Center, Schneider Children’s Hospital, and §Department of Radiology, Long Island

Jewish Medical Center, The Long Island Campus for the Albert Einstein College of Medidne, New Hyde Park, NY.

Presented, in part, at the Child Neurology Society Meeting, San Francisco, California, October 1994.

Received for publication Sep 1, 1994; accepted Nov 21, 1994.

Reprint requests to (J.M.) Division of Pediatric Neurology, Schneider Chil-dren’s Hospital, Long Island Jewish Medical Center, New Hyde Park, NY

11040.

Acad-emy of Pediatrics.

that the maximal rate at which such abnormalities might

appear in this population is 3.8%.

Conclusions. These results indicate that brain

imag-ing studies have very limited value in evaluating head-aches in pediatric patients without clinical evidence of an underlying structural lesion. Pediatrics 199596:413.-416;

headaches, children, magnetic resonance imaging,

corn-puted tomography.

ABBREVIATIONS. CT, computed tomography; MRI, magnetic

resonance imaging; AVM, arteriovenous malformation.

Headaches are a common complaint in childhood.

Bile1 observed that 59% of 8993 school children

ex-perienced headaches, although they were frequent in

only

10%. Sillanap#{228}#{228}2reported that 28% of 2915

chil-dren experienced headaches at least once a month.

Headaches in young children are of particular

con-cern because this is an age group when posterior

fossa brain tumors are more common.3 Physicians

and parents alike are therefore concerned about

young children with headaches.

With the proliferation of brain imaging centers,

increasing

patient

demand

for computed

tomogra-phy (CT) and magnetic resonance imaging (MRI),

and the increasing practice of “defensive medicine,”

neuroimaging

has become

widely

used

to evaluate

headaches.4 The use of these tests for evaluating all

new headaches would be prohibitively expensive

and would result in many false-positive findings.5

Most of the medical literature regarding the

utility

of

brain imaging in headache patients is based on adult

case series, and the recommendations are not always

clear.4’6 There are only two studies in the literature to

guide

the physician when deciding the value of

rou-tine CT or MM studies for children with

head-aches.3’7 Both studies used mostly3 or only7 CT scans,

and either included a small number of patients who

had imaging studies or were limited to children 7

years old or younger.3 The present study was

(2)

414 BRAIN IMAGING IN CHILDREN WITH HEADACHES such as brain tumors, vascular anomalies (arterio-venous malformation

[AVMI,

aneurysm, subdural hematoma), or hydrocephalus in children evaluated for chronic headaches in a tertiary care pediatric

facility

in New York.

METHODS

Description of Institution and Patients

The study involved 133 children who were evaluated for

head-aches as their sole complaint between January 1, 1991 through December 31, 1992. Patients’ follow-up continued until July 1994. All patients were referred by their primary physicians to the

Division of Pediatric Neurology of the Schneider Children’s

Hos-pital, a tertiary-care facility located on the border between Queens and Nassau counties in New York. The CT scanner used was a GE

9800 and the MRI scanner was a Siemens 1 .0-tesla Magneton.

Identification of Headache Patients

All patients 18 years or younger who had recurrent headaches for more than I week’s duration and were referred to the pediatric

neurology clinic were eligible for inclusion in the study. The

patients were identified retrospectively in a database of all pedi-atric neurology patients. Patients with acute onset of headaches

who first presented to the emergency department were excluded,

as were patients with a secondary condition other than headache

that would prompt a brain-imaging procedure. The exclusion

criteria were largely based on the literature: previous neurosurgi-cal procedure, history of seizures, recent head trauma (less than 4 months before evaluation), and prior neurologic abnormalities.5 Children with abnormal neurologic examinations were included if the presenting complaint was headache and the physical abnor-malities were found by the neurologist at the time of the headache evaluation. One of us (J.M.) reviewed the patients’ charts, with

attention focused on the sex and age of the patient, headache

classification, and clinical indications that prompted the

neurolo-gist to order a CT or an MRI scan. All patients were seen by one

of us (J.M., L.E.), either directly or as the clinic attending physi-cian.

Clinical Diagnosis and Indications for Brain Imaging

The clinical diagnosis of childhood migraine in this study was

based mostly on the diagnostic criteria of Prensky and Sommer.8 These criteria include recurrent headaches separated by symptom-free intervals, in conjunction with three or more of the following

six features: (1) abdominal pain or nausea/vomiting with the

headache; (2) hemicranial headaches; (3) throbbing pulsatile qual-ity of headaches; (4) complete relief after a brief period of rest; (5)

a visual, sensory, or motor aura; and (6) history of migraine

headaches in one or more members of the immediate family. The

results of the CT and MRI scans were reviewed with special

emphasis on potentially treatable lesions, ie, brain tumors, vascu-lar anomalies, and hydrocephalus. We recorded all symptoms and

signs and all clinical features that prompted the neurologist to

order the brain imaging (within the limitations of a retrospective study). The results of the brain imaging were reviewed and cor-related with the patient’s complaints and diagnosis.

RESULTS

Patient Population and Clinical Classification

A total of 133 children met the criteria for inclusion in this study. The mean age at the time of brain imaging was I 1 .3 years (range, 3 to 18 years). There

were 79 males (59%) and 54 females (41 %). Headache

types were classified in 108 (81

%)

of the cases (Table

1). Migraine headaches accounted for 52% of the patients, with common migraine headache the most

frequent. There was one case of confusional migraine

and two cases of migraine variant, including one patient with cyclic vomiting and one with paroxys-mal vertigo. In two patients, headaches were

associ-ated with a recent history of minor head trauma

TABLE 1. Headache Classification

Headaches Imaging

n % n %

Vascular migrainous 69 52 43 62

Common migraine 57 83 34 60

Classic migraine 9 13 6 7

Confusional migraine I I I 100

Migraine variant 2 3 2 100

Chronic tension 28 21 12 43

Mixed tension-migraine 4 3 3 75

Psychogenic 2 1.5 2 100

Post-traumatic 2 1.5 1 50

Other 3 2 1 33

Unclassified 25 19 16 64

Total 133 100 78 59

(more than 4 months after the event). Two cases of

psychogenic headache involved two children with

depression presenting as headaches. Other types of

headaches included two patients who were being

weaned off prednisone treatment and one with sinus

headache.

Brain-Imaging Studies

A total of 78 patients had brain-imaging studies: 27 had CT scan, 45 had Mifi, and 6 had both. Among the indications frequently recorded in the charts for

per-forming

brain scans were an atypical headache

pat-tern that was not clearly consistent with a specific,

well-defined headache type; the presence of

neuro-logic disturbances during the attacks, ie, hemiplegia

or persistent focal symptoms or signs; presence of

abnormal neurologic findings; and the appearance of

systemic symptoms, ie, excessive fatigue or weight

loss (Table 2). In nearly one third of the patients,

imaging

was

done solely because of parents’ or

phy-sicians’ concerns about the possibility of brain

hi-mors. No specific reason was given for the brain

imaging in 17 patients. Studies were done with

ap-proximately equal frequency in young and older

children: 57% in children 11 years or younger and

61 % in children 12 years or older (P = .36,

x

test)

(Table 1). Brain imaging was also performed rather

nonspecifically according to the etiologic

classifica-tion: 62% and 55% of vascular migraine and

non-migraine headache patients, respectively, had

imag-ing studies (P .47,

x

test) (Table 1).

TABLE 2. Indications for Brain Imaging in 78 Pediatric Patients With Headaches*

Indication n

Headache onset at young age (<5 y) 4

Atypical headache pattern 12

Increasing severity or frequency of headaches 5

Abnormalities on ocular or neurologic examination 6 Headache provoked by change of position of the head 2

Focal symptoms or signs during headaches 7

Systemic symptoms, ie, fatigue, weight loss 11

Parental concern about cerebral mass 12

Physician concern about cerebral mass II

Not specified 17

Total 87

*In nine patients, more than one indication for brain imaging was given.

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

(3)

Eleven patients had abnormal radiologic findings:

Four had cerebral abnormalities and seven had

mod-erate to severe mucopenosteal thickening of the

na-sal sinuses. None of the cerebral abnormalities were directly correlated to the headaches, and all were

deemed unrelated to the presenting complaint of

headache. In one patient with a 2-week history of

headaches lasting 15 to 30 minutes, a small

neuro-epithelial cyst was found adjacent to the foramen of

Monroe. The patient was treated conservatively,

with follow-up of nearly 2 years revealing no interval

change in the size of the lesion. Another patient’s

MRI

showed a left cerebral hemiatrophy, and his

physical examination revealed a mild right

lower-limb atrophy. In a third patient, the MRI showed

Dandy-Walker variant malformation, and in a fourth

patient, the MRI disclosed a right temporal

arach-noid cyst but with no evidence of deviation of

mid-line structures or hemosiderin in or around the cyst. Results of MRI showed mucoperiosteal thickening in

seven patients

(5%)

involving one or more sinuses.

This MRI pattern was not related to either acute

sinusitis or headache. Only one of these patients was

treated for possible sinusitis, and all showed

sponta-neous improvement of their headaches. Physical

ab-normalities

were found in five other patients who

were being evaluated for their headaches: Three had

blurred optic discs, one had short stature, and one

was microcephalic. The MRI studies were normal in

these patients. None of the brain scans in the 78

patients studied revealed potentially treatable

le-sions such as brain tumors, vascular abnormalities,

or hydrocephalus.

These data allow us to estimate the upper limit for

the rate of relevant brain-imaging abnormalities in a

population of children with chronic headaches.

As-suming that the true rate is r, then the probability

that any given child presenting with headaches and

fulfilling the entry criteria of our study will have a

negative imaging study is (1 - r), and the probability

that 78 children will have negative studies is (1

-The commonly accepted cutoff value for making a

type 1 error (ie, accepting a false-positive finding) is

5%, or 0.05. Inserting these values into the equation

allows us to solve for r: r = 1 - (0.05)1’78 = 0.038.

Thus, there is a 95% probability that the true rate of

relevant abnormalities on brain-imaging studies in

children with headaches is 3.8% or less.9

DISCUSSION

The findings of our study indicate that

brain-imaging studies are quite unlikely to demonstrate a

treatable structural lesion in children with chronic

headaches. In this study, four headache patients, or

3% of the total subjects, had abnormal findings on

brain imaging. However, the studies revealed no

evidence of hydrocephalus, increased intracranial

pressure, or any potentially treatable disease, and the

findings

were deemed incidental. These results

con-firm and extend the findings reported in two

previ-ous studies that evaluated the utility of brain

imag-ing in ruling out potentially treatable conditions in

children evaluated for headaches. One

study7

in-cluded l57 children with headaches; 7 patients had a

CT scan and 1 patient with downward eye deviation

during

the headache was found to have choroid

plexus papifioma. A second study evaluated

head-ache characteristics in 104 children aged 7 years or

younger.3 Brain-imaging studies were performed in

30 patients; 5 abnormal neuroimaging studies were

deemed incidental. The authors suggested that in the

setting of a normal neurologic evaluation and a

his-tory

consistent with migraine, careful evaluation and observation of these children over time can safely

obviate the need for brain imaging.

Honig and Charney’#{176}analyzed the history and the

radiologic findings in 72 children with headaches

secondary to brain tumors. In their series, the

major-ity of children already had other complaints and

neurologic abnormalities on initial presentation.

Al-most all children had abnormal neurologic findings

within a few months of presentation. The authors

proposed a number of conditions that indicate the

need for CT scan in children with headache. These

include the presence of physical or neurologic abnor-malities, persistent vomiting, change in the character

of headaches, and age less than 3 years.

The literature regarding the utility of brain

imag-ing in the evaluation of headache in adults with

normal

neurologic examinations was reviewed

re-cently.4 The review included 17 published studies,

each with 18 patients or more. All articles except one

were case reports of uncontrolled series. The largest

studies

were of CT scan in headache patients,3

whereas the MRI

studies

of headache patients were

relatively small.14”5 All data were pooled to include

one category of headaches without any specific

di-agnosis and another category that included only

mi-graine headaches. Available data from abnormal CT

or M scans in migraine included a total of 897

patients. Three patients (0.3%) were found to have

brain tumors and one patient (0.1 %) had an AVM.

The overall rate of potentially treatable lesions was

0.4%. The rate of potentially treatable lesions in

pa-tients with unspecified headache was 2.4%,

includ-ing I % tumors, 0.3% AVM, 0.4% hydrocephalus,

0.2% aneurysm, and 0.3% subdural hematoma.

Based on these data, the

Quality

Standards

Subcom-mittee of the American Academy of Neurology

sug-gested that routine use of brain imaging is not war-ranted for adult patients with recurrent headaches

that have been defined as migraine with no recent

change in pattern, no history of seizures, and no

other focal neurologic signs or symptoms.16

How-ever, CT or MRI may be indicated for patients with

atypical

headache patterns, a history of seizures, or

focal signs or symptoms. There is not enough

infor-mation at present to define the roles of CT and MRI

in the evaluation of patients with headaches that are

not consistent with migraine.

Our results indicate a 95% probability that the

rate of finding relevant abnormalities on

brain-imaging studies in children with chronic

head-aches is at most 3.8%. This estimate is consistent

with the yield for brain-imaging studies in adult

headache patients.4 It should be emphasized that

the true rate of relevant abnormalities may be even

(4)

416 BRAIN IMAGING IN CHILDREN WITH HEADACHES Many clinicians feel uncomfortable dealing with headaches in children. This uncertainty, coupled with parental concern about the headaches and the increasing practice of “defensive medicine,” may

influence the decision regarding the need for brain

imaging.4 Nearly one third, and possibly more, of

our patients were scanned because of these

con-cerns. Although CT and MRI studies are relatively safe, they are expensive and carry the additional risk of deep sedation. We feel that brain imaging is indicated in the very young or in cases when

din-ical history cannot be reliably obtained. The

rou-tine use of neuroimaging is indicated in cases

where there is evidence of a focal neurologic

ab-normality, as documented by history or by

exam-ination, and when there is a clinical suspicion of an

underlying structural lesion. When there is no real

clinical suspicion, as in well-defined migraine,

brain imaging is not warranted. In these cases, as already suggested,’7 we should resist the pressures

of patients and doctors to perform these studies.

REFERENCES

I- Bille B. Migraine in school children. Acta Pediatr. 1962;51 (Suppi 136): 1-151

2. Sillanap#{228}#{228}M. Changes in the prevalence of migraine and other

head-aches during the first seven school years. Headache. 1983;23i5-19 3. Chu ML, Shinnar S. Headaches in children younger than 7 years of age.

Arch Neurol. 1992;49:79-82

4. Fnshberg BM. The utility of neuroimaging in the evaluation of

head-ache in patients with normal neurologic examinations. Neurology. 1994;

44:1191-1197

5. Weingarten S, Kleinman M, Elperin L, Larson EB. The effectiveness of cerebral imaging in the diagnosis of chronic headache. Arch Intern Med. 1992;152:2457-2462

6. NIH Consensus Development Panel. Computed tomography scanning

of the brain. In: Proceedings From the National Institutes of Health Consen-sus Development Conference Summary. Vol. 4(2). Bethesda, MD: National

Institutes of Health, Government Printing Office; 1982

7. Dooley JM, Campfield PR, O’Neffl M, Vohra A. The value of CT scans

for children with headaches. Can JNeurol Sci. 1990;17:309-310

8. Prensky AL, Sommer D. Diagnosis and treatment of migraine in

chil-dren. Neurology. 1979;29:506-509

9. Hanley JA, Uppman-Hand A. If nothing goes wrong, is everything all

right? JAMA. 1983;249:1743-1745

10. Honig PJ, Charney EB. Children with brain tumor headaches. Am JDis Child. 1982;136:121-124

11. Mitchell C, Osborn R, Grosskreutz S. Computerized tomography in the

headache patient: is routine evaluation really necessary? Headache. 1993;

33:82-86

12. Baker H. Cranial CT in the investigation of headache: cost effectiveness for brain tumors. JNeuroradiol. 1983;10:112-116

13. Cuetter A, Aita J. CT scanning in classic migraine (letter). Headache.

1983;23:195

14. Kuhn M, Shekar P. A comparative study of magnetic resonance imaging and computed tomography in the evaluation of migraine. Comput Med Imaging Graph. 1990;14:149-152

15. Igarashi H, Sakai F, Tazaki Y, Kan S. Saito Y. Magnetic resonance

imaging of migraine. Cephalalgia. 1989;9(suppl 10):189-190

16. Report of the Quality Standards Subcommittee of the American

Acad-emy of Neurology. Practice parameter: the utility of neuroimaging in the evaluation of headache in patients with normal neurologic exami-nations. Neurology. 1994;44:1353-1354

17. Green SH. Who needs a brain scan? Arch Dis Child. 1987;62:1094-1096

SEE THE TREE-MISS THE FOREST

We spend volumes agonizing and debating informed consent, autonomy,

dis-continuation of life support systems, and the like, but little time debating the

system . . . The sum total of our ethical thinking about individuals has given us an

unethical health care system. Alas, no modern nation can build a health care

system one individual at a time.

Lamm RD. The Ethics of Excess. Hastings Center Report. 1994:(Nov-Dec), 14.

Submitted by Student

(5)

1995;96;413

Pediatrics

Joseph Maytal, Robert S. Bienkowski, Mahendra Patel and Lydia Eviatar

The Value of Brain Imaging in Children With Headaches

Services

Updated Information &

http://pediatrics.aappublications.org/content/96/3/413

including high resolution figures, can be found at:

Permissions & Licensing

http://www.aappublications.org/site/misc/Permissions.xhtml

entirety can be found online at:

Information about reproducing this article in parts (figures, tables) or in its

Reprints

http://www.aappublications.org/site/misc/reprints.xhtml

(6)

1995;96;413

Pediatrics

Joseph Maytal, Robert S. Bienkowski, Mahendra Patel and Lydia Eviatar