Occipital Headaches and Neuroimaging in Children

Abstract

Objective: To investigate the common thinking, as reinforced by the International Classification of Headache Disorders, 3rd edition (beta), that occipital headaches in children are rare and suggestive of serious intracranial pathology.Methods: We performed a retrospective chart review cohort study of all patients #18 years of age referred to a university child neurology clinic for headache in 2009. Patients were stratified by headache location: solely occipital, occipital plus other area(s) of head pain, or no occipital involvement. Children with abnormal neurologic examinations were excluded. We assessed location as a predictor of whether neuroimaging was ordered and whether intracranial pathology was found. Analyses were performed with cohort study tools in Stata/SE 13.0 (StataCorp, College Station, TX).Results: A total of 308 patients were included. Median age was 12 years (32 months-18 years), and 57% were female. Headaches were solely occipital in 7% and occipital-plus in 14%. Patients with occipital head pain were more likely to undergo neuroimaging than those without occipital involvement (solely occipital: 95%, relative risk [RR] 10.5, 95% confidence interval [CI] 1.4-77.3; occipital-plus: 88%, RR 3.7, 95% CI 1.5-9.2; no occipital pain: 63%, referent). Occipital pain alone or with other locations was not significantly associated with radiographic evidence of clinically significant intracranial pathology.Conclusions: Children with occipital headache are more likely to undergo neuroimaging. In the absence of concerning features on the history and in the setting of a normal neurologic examination, neuroimaging can be deferred in most pediatric patients when occipital pain is present. With a pediatric migraine prevalence of 3.9% to 11%1-3 and a lifetime aggregate prevalence of 54.4% 2 for all pediatric headaches, a rational approach to the use of costly diagnostic studies is needed. The American Academy of Neurology/Child Neurology Society practice parameter states that neuroimaging is not indicated in a child with recurrent headache and a normal neurologic examination. 4 Nonetheless, 45% of children with nonacute recurrent headaches will receive at least one neuroimaging study without clinical benefit. 5The American Academy of Neurology/Child Neurology Society practice parameter supports the use of neuroimaging in patients with recurrent headaches and abnormal neurologic examination findings, seizures, or a history of recent-onset severe headache or recent changes in the nature of the headache. 4 Multiple pediatric emergency department (ED) studies have tried to identify warning signs deserving further workup, 6-10 and 2 of the studies suggested that an occipital headache location signified intracranial pathology. 7,9 Other warning signs not addressed in the practice parameter included younger age, severe intensity, and an inability to describe the quality of the pain.

Dedicated neuroimaging in children with primary headache: prevalence of lesions and comparison between migraine and non-migraine

“…Additionally, these abnormal results can also occur in healthy controls as random results, which is in close concordance with our results [16][17][18][19]. The most common ndings in our study were dilated perivascular space, sinusitis, and cystic lesion (arachnoid cysts).…”

“…This is consistent with the results of our study. The mechanism is explained in such a way that it causes facial and head pain due to the action of the trigeminal nerve branch that innervates sensory of the sinuses and nasal mucosa [19]. In other ndings, none of these could directly affect the diagnosis and treatment plan decision for migraine or other headaches.…”

Dedicated neuroimaging analysis in children with primary headaches: prevalence of lesions and a comparison between patients with and without migraines

“…Sinusitis was the major cause of headaches. According to a previous meta-analysis, the common brain imaging finding in children with headaches included sinusitis, arachnoid cyst, unspecified white matter changes, enlarged cisterna magna, partial empty sella, and choroid plexus cyst [ 16 – 19 ]. Among them, sinusitis is known as a potential cause of headaches in both adults and children.…”

Headache in the Pediatric Population: Focus on Migraine

“…[33][34][35] Of note, while occipital location of headache alone was previously considered a reason to obtain neuroimaging, studies have shown that this does not necessarily indicate a dangerous cause of headache in the absence of an abnormal exam or other concerning symptoms. 51,52 Treatment for Pediatric Migraine…”