CT Scans May Not Be Helpful for Most Young Children With Emergent Headache

From Medscape Medical News

July 29, 2009 — Computed tomographic (CT) scans seldom lead to diagnosis or contribute to immediate management of young children presenting to the emergency department with headache but normal neurologic examination findings and nonworrying history, according to the results of a study reported in the July issue of Pediatrics.

"Neuroimaging because of recurrent childhood headaches has limited value; especially in the setting of normal physical examination," write Tarannum M. Lateef, MD, from George Washington University School of Medicine and Children's National Medical Center in Washington, DC, and colleagues. "The risk of radiation exposure from CT scans is highest in the youngest age group. This study addresses the diagnostic utility of CT scans, in an ED [emergency department] setting, for children <6 years of age."

The investigators evaluated the records of 364 children aged 2 to 5 years seen between July 1, 2003, and June 30, 2006, in a large urban emergency department for evaluation of headache. Patients with headaches secondary to clearly apparent causes such as ventriculoperitoneal shunts, known brain tumor, or acute illnesses including viral syndromes, fever, probable meningitis, or trauma were identified based on initial history and examination findings. For the remaining patients, headache history, neurologic findings, results of laboratory and neuroimaging tests, discharge diagnosis, and disposition were reviewed.

Among 306 children (84%) with secondary headaches identified from initial history and physical examination, acute febrile illnesses, and viral respiratory tract syndromes were thought to be responsible for the headaches in 72%.

CT scans were performed in 16 (28%) of the 58 children (16% of the total study sample) with no evident central nervous system disease or systemic illness diagnosed at presentation. In 15 (94%) of these 16 patients, CT scans did not facilitate diagnosis or management. Only 1 scan result was abnormal, revealing a brainstem glioma, but this patient had abnormal findings on neurologic examination when first evaluated in the emergency department. Family history was not documented in 59% of children who were thought to have primary headaches.

"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," the study authors write. "A family history often is contributory and should be part of the evaluation of young children with headache in the ED. CT imaging poses risk (which is greatest for the youngest children), is expensive, and usually is without benefit."

Limitations of this study include retrospective design, lack of complete follow-up monitoring, and analysis limited to information in clinical records. Most children studied did not have a documented family history or a thorough headache history.

"Studies such as this one can contribute to recognition of medical interventions for which indications need rethinking," the study authors conclude.