Headache-Child

Variant: 1 Child. Primary headache. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
Radiography skull	Usually Not Appropriate	☢☢
Arteriography cerebral	Usually Not Appropriate	☢☢☢☢
MRA head without IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRI head without IV contrast	Usually Not Appropriate	O
MRV head with IV contrast	Usually Not Appropriate	O
MRV head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢
CTV head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 2 Child. Secondary headache. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
MRA head without IV contrast	May Be Appropriate	O
MRV head without IV contrast	May Be Appropriate	O
CT head without IV contrast	May Be Appropriate	☢☢☢
CTA head with IV contrast	May Be Appropriate	☢☢☢☢
CTV head with IV contrast	May Be Appropriate	☢☢☢☢
Radiography skull	Usually Not Appropriate	☢☢
Arteriography cerebral	Usually Not Appropriate	☢☢☢☢
MRV head with IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 3 Child. Sudden severe headache (thunderclap headache). Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRA head without IV contrast	Usually Appropriate	O
MRI head without IV contrast	Usually Appropriate	O
CT head without IV contrast	Usually Appropriate	☢☢☢
CTA head with IV contrast	May Be Appropriate	☢☢☢☢
Radiography skull	Usually Not Appropriate	☢☢
Arteriography cerebral	Usually Not Appropriate	☢☢☢☢
MRI head without and with IV contrast	Usually Not Appropriate	O
MRV head with IV contrast	Usually Not Appropriate	O
MRV head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CTV head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 4 Child. Headache attributed to infection. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without and with IV contrast	Usually Appropriate	O
MRA head without IV contrast	May Be Appropriate	O
MRI head without IV contrast	May Be Appropriate	O
MRV head with IV contrast	May Be Appropriate	O
MRV head without IV contrast	May Be Appropriate	O
CT head with IV contrast	May Be Appropriate	☢☢☢
CT head without IV contrast	May Be Appropriate	☢☢☢
Radiography skull	Usually Not Appropriate	☢☢
Arteriography cerebral	Usually Not Appropriate	☢☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢
CTV head with IV contrast	Usually Not Appropriate	☢☢☢☢

Variant: 5 Child. Headache attributed to remote trauma. Initial imaging.

Procedure	Appropriateness Category	Peds Relative Radiation Level
MRI head without IV contrast	Usually Appropriate	O
Radiography skull	Usually Not Appropriate	☢☢
Arteriography cerebral	Usually Not Appropriate	☢☢☢☢
MRA head without IV contrast	Usually Not Appropriate	O
MRI head without and with IV contrast	Usually Not Appropriate	O
MRV head with IV contrast	Usually Not Appropriate	O
MRV head without IV contrast	Usually Not Appropriate	O
CT head with IV contrast	Usually Not Appropriate	☢☢☢
CT head without and with IV contrast	Usually Not Appropriate	☢☢☢☢
CT head without IV contrast	Usually Not Appropriate	☢☢☢
CTA head with IV contrast	Usually Not Appropriate	☢☢☢☢
CTV head with IV contrast	Usually Not Appropriate	☢☢☢☢

Panel Members

Laura L. Hayes, MD^a; Susan Palasis, MD^b; Twyla B. Bartel, DO^c; Timothy N. Booth, MD^d; Ramesh S. Iyer, MD^e; Jeremy Y. Jones, MD^f; Nadja Kadom, MD^g; Sarah S. Milla, MD^h; John S. Myseros, MDⁱ; Ann Pakalnis, MD^j; Sonia Partap, MD, MS^k; Richard L. Robertson, MD^l; Maura E. Ryan, MD^m; Gaurav Saigal, MDⁿ; Bruno P. Soares, MD^o; Aylin Tekes, MD^p; Boaz Karmazyn, MD^q.

Summary of Literature Review

Introduction/Background

Overview of Imaging Modalities Radiography

Discussion of Procedures by Variant

Variant 1: Child. Primary headache. Initial imaging.

Variant 1: Child. Primary headache. Initial imaging.
A. Radiography

Variant 1: Child. Primary headache. Initial imaging.
B. MRI

Variant 1: Child. Primary headache. Initial imaging.
C. CT

Variant 1: Child. Primary headache. Initial imaging.
D. CTA

Variant 1: Child. Primary headache. Initial imaging.
E. CTV

Variant 1: Child. Primary headache. Initial imaging.
F. MRA

Variant 1: Child. Primary headache. Initial imaging.
G. MRV

Variant 1: Child. Primary headache. Initial imaging.
H. Arteriography

Variant 2: Child. Secondary headache. Initial imaging.

Variant 2: Child. Secondary headache. Initial imaging.
A. Radiography

Variant 2: Child. Secondary headache. Initial imaging.
B. MRI

Variant 2: Child. Secondary headache. Initial imaging.
C. CT

Variant 2: Child. Secondary headache. Initial imaging.
D. CTA

Variant 2: Child. Secondary headache. Initial imaging.
E. CTV

Variant 2: Child. Secondary headache. Initial imaging.
F. MRA

Variant 2: Child. Secondary headache. Initial imaging.
G. MRV

Variant 2: Child. Secondary headache. Initial imaging.
H. Arteriography

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
A. Radiography

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
B. MRI

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
C. CT

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
D. CTA

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
E. CTV

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
F. MRA

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
G. MRV

Variant 3: Child. Sudden severe headache (thunderclap headache). Initial imaging.
H. Arteriography

Variant 4: Child. Headache attributed to infection. Initial imaging.

Variant 4: Child. Headache attributed to infection. Initial imaging.
A. Radiography

Variant 4: Child. Headache attributed to infection. Initial imaging.
B. MRI

Variant 4: Child. Headache attributed to infection. Initial imaging.
C. CT

Variant 4: Child. Headache attributed to infection. Initial imaging.
D. CTA

Variant 4: Child. Headache attributed to infection. Initial imaging.
E. CTV

Variant 4: Child. Headache attributed to infection. Initial imaging.
F. MRA

Variant 4: Child. Headache attributed to infection. Initial imaging.
G. MRV

Variant 4: Child. Headache attributed to infection. Initial imaging.
H. Arteriography

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
A. Radiography

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
B. MRI

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
C. CT

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
D. CTA

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
E. CTV

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
F. MRA

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
G. MRV

Variant 5: Child. Headache attributed to remote trauma. Initial imaging.
H. Arteriography

Summary of Highlights

Summary of Evidence

Supporting Documents

The evidence table, literature search, and appendix for this topic are available at https://acsearch.acr.org/list. The appendix includes the strength of evidence assessment and the final rating round tabulations for each recommendation.

For additional information on the Appropriateness Criteria methodology and other supporting documents, please go to the ACR website at https://www.acr.org/Clinical-Resources/Clinical-Tools-and-Reference/Appropriateness-Criteria.

Appropriateness Category Names and Definitions

Appropriateness Category Name	Appropriateness Rating	Appropriateness Category Definition
Usually Appropriate	7, 8, or 9	The imaging procedure or treatment is indicated in the specified clinical scenarios at a favorable risk-benefit ratio for patients.
May Be Appropriate	4, 5, or 6	The imaging procedure or treatment may be indicated in the specified clinical scenarios as an alternative to imaging procedures or treatments with a more favorable risk-benefit ratio, or the risk-benefit ratio for patients is equivocal.
May Be Appropriate (Disagreement)	5	The individual ratings are too dispersed from the panel median. The different label provides transparency regarding the panel’s recommendation. “May be appropriate” is the rating category and a rating of 5 is assigned.
Usually Not Appropriate	1, 2, or 3	The imaging procedure or treatment is unlikely to be indicated in the specified clinical scenarios, or the risk-benefit ratio for patients is likely to be unfavorable.

Relative Radiation Level Information

Potential adverse health effects associated with radiation exposure are an important factor to consider when selecting the appropriate imaging procedure. Because there is a wide range of radiation exposures associated with different diagnostic procedures, a relative radiation level (RRL) indication has been included for each imaging examination. The RRLs are based on effective dose, which is a radiation dose quantity that is used to estimate population total radiation risk associated with an imaging procedure. Patients in the pediatric age group are at inherently higher risk from exposure, because of both organ sensitivity and longer life expectancy (relevant to the long latency that appears to accompany radiation exposure). For these reasons, the RRL dose estimate ranges for pediatric examinations are lower as compared with those specified for adults (see Table below). Additional information regarding radiation dose assessment for imaging examinations can be found in the ACR Appropriateness Criteria^® Radiation Dose Assessment Introduction document.

Relative Radiation Level Designations
Relative Radiation Level*	Adult Effective Dose Estimate Range	Pediatric Effective Dose Estimate Range
O	0 mSv	0 mSv
☢	<0.1 mSv	<0.03 mSv
☢☢	0.1-1 mSv	0.03-0.3 mSv
☢☢☢	1-10 mSv	0.3-3 mSv
☢☢☢☢	10-30 mSv	3-10 mSv
☢☢☢☢☢	30-100 mSv	10-30 mSv
*RRL assignments for some of the examinations cannot be made, because the actual patient doses in these procedures vary as a function of a number of factors (e.g., region of the body exposed to ionizing radiation, the imaging guidance that is used). The RRLs for these examinations are designated as “Varies.”

References

1.	Lateef TM, Grewal M, McClintock W, Chamberlain J, Kaulas H, Nelson KB. Headache in young children in the emergency department: use of computed tomography. Pediatrics. 2009; 124(1):e12-17.
2.	Lewis DW, Ashwal S, Dahl G, et al. Practice parameter: evaluation of children and adolescents with recurrent headaches: report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002; 59(4):490-498.
3.	International Headache Society. ICHD / Guidelines. Available at: http://www.ihs-headache.org/ichd-guidelines.
4.	Arruda MA, Guidetti V, Galli F, Albuquerque RC, Bigal ME. Primary headaches in childhood--a population-based study. Cephalalgia. 2010; 30(9):1056-1064.
5.	Schwedt TJ, Guo Y, Rothner AD. "Benign" imaging abnormalities in children and adolescents with headache. Headache. 2006; 46(3):387-398.
6.	Sempere AP, Porta-Etessam J, Medrano V, et al. Neuroimaging in the evaluation of patients with non-acute headache. Cephalalgia. 2005; 25(1):30-35.
7.	Nallasamy K, Singhi SC, Singhi P. Approach to headache in emergency department. Indian J Pediatr. 79(3):376-80, 2012 Mar.
8.	Raieli V, Eliseo M, Pandolfi E, et al. Recurrent and chronic headaches in children below 6 years of age. J Headache Pain. 2005; 6(3):135-142.
9.	Alexiou GA, Argyropoulou MI. Neuroimaging in childhood headache: a systematic review. [Review]. Pediatr Radiol. 43(7):777-84, 2013 Jul.
10.	DeVries A, Young PC, Wall E, et al. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics. 132(1):e1-8, 2013 Jul.
11.	Martens D, Oster I, Gottschlling S, et al. Cerebral MRI and EEG studies in the initial management of pediatric headaches. Swiss Med Wkly. 142:w13625, 2012.
12.	Yilmaz U, Celegen M, Yilmaz TS, Gurcinar M, Unalp A. Childhood headaches and brain magnetic resonance imaging findings. Europ J Paediatr Neurol. 18(2):163-70, 2014 Mar.
13.	Rho YI, Chung HJ, Suh ES, et al. The role of neuroimaging in children and adolescents with recurrent headaches--multicenter study. Headache. 2011;51(3):403-408.
14.	Roser T, Bonfert M, Ebinger F, Blankenburg M, Ertl-Wagner B, Heinen F. Primary versus secondary headache in children: a frequent diagnostic challenge in clinical routine. [Review]. Neuropediatrics. 44(1):34-9, 2013 Feb.
15.	Abu-Arafeh I, Macleod S. Serious neurological disorders in children with chronic headache. Arch Dis Child. 2005; 90(9):937-940.
16.	American College of Radiology. ACR Appropriateness Criteria®: Head Trauma — Child. Available at: https://acsearch.acr.org/docs/3083021/Narrative/.
17.	Dowling MM, Noetzel MJ, Rodeghier MJ, et al. Headache and migraine in children with sickle cell disease are associated with lower hemoglobin and higher pain event rates but not silent cerebral infarction. J Pediatr. 164(5):1175-1180.e1, 2014 May.
18.	Ozge A, Termine C, Antonaci F, Natriashvili S, Guidetti V, Wober-Bingol C. Overview of diagnosis and management of paediatric headache. Part I: diagnosis. J Headache Pain. 2011;12(1):13-23.
19.	American College of Radiology. ACR Appropriateness Criteria®: Seizures — Child. Available at: https://acsearch.acr.org/docs/69441/Narrative/.
20.	Mortimer AM, Bradley MD, Stoodley NG, Renowden SA. Thunderclap headache: diagnostic considerations and neuroimaging features. [Review]. Clin Radiol. 68(3):e101-13, 2013 Mar.
21.	Bederson JB, Connolly ES Jr, Batjer HH, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. [Review] [509 refs]. Stroke. 40(3):994-1025, 2009 Mar.
22.	Morgenstern LB, Hemphill JC 3rd, Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 41(9):2108-29, 2010 Sep.
23.	American College of Radiology. ACR Appropriateness Criteria®: Sinusitis — Child. Available at: https://acsearch.acr.org/docs/69442/Narrative/.
24.	Degnan AJ, Levy LM. Pseudotumor cerebri: brief review of clinical syndrome and imaging findings. AJNR Am J Neuroradiol. 2011;32(11):1986-1993.
25.	Linn J, Ertl-Wagner B, Seelos KC, et al. Diagnostic value of multidetector-row CT angiography in the evaluation of thrombosis of the cerebral venous sinuses. AJNR. 2007; 28(5):946-952.
26.	Abend NS, Younkin D, Lewis DW. Secondary headaches in children and adolescents. Semin Pediatr Neurol. 2010; 17(2):123-133.
27.	American College of Radiology. ACR Appropriateness Criteria®: Cerebrovascular Disease. Available at: https://acsearch.acr.org/docs/69478/Narrative/.
28.	Gelfand AA, Reider AC, Goadsby PJ. Cranial autonomic symptoms in pediatric migraine are the rule, not the exception. Neurology. 2013;81(5):431-436.
29.	American College of Radiology. ACR Appropriateness Criteria®: Suspected Physical Abuse–Child. Available at: https://acsearch.acr.org/docs/69443/Narrative/.
30.	The epidemiology of headache among children with brain tumor. Headache in children with brain tumors. The Childhood Brain Tumor Consortium. J Neurooncol. 1991; 10(1):31-46.
31.	Medina LS, Pinter JD, Zurakowski D, Davis RG, Kuban K, Barnes PD. Children with headache: clinical predictors of surgical space-occupying lesions and the role of neuroimaging. Radiology. 1997; 202(3):819-824.
32.	Reulecke BC, Erker CG, Fiedler BJ, Niederstadt TU, Kurlemann G. Brain tumors in children: initial symptoms and their influence on the time span between symptom onset and diagnosis. J Child Neurol. 23(2):178-83, 2008 Feb.
33.	Alperin N, Ranganathan S, Bagci AM, et al. MRI evidence of impaired CSF homeostasis in obesity-associated idiopathic intracranial hypertension. AJNR Am J Neuroradiol. 34(1):29-34, 2013 Jan.
34.	Friedman DI, Liu GT, Digre KB. Revised diagnostic criteria for the pseudotumor cerebri syndrome in adults and children. Neurology. 81(13):1159-65, 2013 Sep 24.
35.	Toldo I, Tangari M, Mardari R, et al. Headache in children with Chiari I malformation. Headache. 54(5):899-908, 2014 May.
36.	Victorio MC, Khoury CK. Headache and Chiari I Malformation in Children and Adolescents. [Review]. Semin Pediatr Neurol. 23(1):35-9, 2016 Feb.
37.	Eidlitz-Markus T, Zeharia A, Haimi-Cohen Y, Konen O. Occipital and craniocervical pain and brain MRI in children with migraine. Pediatr Neurol. 2014;50(4):347-352.
38.	Hines PC, McKnight TP, Seto W, Kwiatkowski JL. Central nervous system events in children with sickle cell disease presenting acutely with headache. J Pediatr. 159(3):472-8, 2011 Sep.
39.	Ahad R, Kossoff EH. Secondary intracranial causes for headaches in children. Curr Pain Headache Rep. 2008; 12(5):373-378.
40.	Alperin N, Lam BL, Tain RW, et al. Evidence for altered spinal canal compliance and cerebral venous drainage in untreated idiopathic intracranial hypertension. Acta Neurochir Suppl. 2012;114:201-205.
41.	Dwyer CM, Prelog K, Owler BK. The role of venous sinus outflow obstruction in pediatric idiopathic intracranial hypertension. J Neurosurg Pediatr. 2013;11(2):144-149.
42.	Rohr A, Dorner L, Stingele R, Buhl R, Alfke K, Jansen O. Reversibility of venous sinus obstruction in idiopathic intracranial hypertension. AJNR Am J Neuroradiol. 2007;28(4):656-659.
43.	Aiken AH, Hoots JA, Saindane AM, Hudgins PA. Incidence of cerebellar tonsillar ectopia in idiopathic intracranial hypertension: a mimic of the Chiari I malformation. AJNR Am J Neuroradiol. 33(10):1901-6, 2012 Nov.
44.	Agid R, Willinsky RA, Farb RI, Terbrugge KG. Life at the end of the tunnel: why emergent CT angiography should be done for patients with acute subarachnoid hemorrhage. AJNR 2008; 29(6):e45; author reply e46-47.
45.	Kallmes DF, Layton K, Marx WF, Tong F. Death by nondiagnosis: why emergent CT angiography should not be done for patients with subarachnoid hemorrhage. AJNR. 2007; 28(10):1837-1838.
46.	Moran CJ. Aneurysmal subarachnoid hemorrhage: DSA versus CT angiography--is the answer available? Radiology. 2011; 258(1):15-17.
47.	Sabri A, Robbs JV, Maharajh J, Sikwila TC. Descriptive retrospective analysis of the diagnostic yield and morbidity of four vessel catheter-directed cerebral angiography and multidetector computed tomographic angiography (MDCTA) performed at Inkosi Albert Luthuli Central Hospital (IALCH). Eur J Radiol. 2011;80(2):498-501.
48.	Westerlaan HE, van Dijk MJ, Jansen-van der Weide MC, et al. Intracranial aneurysms in patients with subarachnoid hemorrhage: CT angiography as a primary examination tool for diagnosis--systematic review and meta-analysis. Radiology. 2011; 258(1):134-145.
49.	Mitchell P, Wilkinson ID, Hoggard N, et al. Detection of subarachnoid haemorrhage with magnetic resonance imaging. J Neurol Neurosurg Psychiatry. 2001;70(2):205-211.
50.	Dubosh NM, Bellolio MF, Rabinstein AA, Edlow JA. Sensitivity of Early Brain Computed Tomography to Exclude Aneurysmal Subarachnoid Hemorrhage: A Systematic Review and Meta-Analysis. [Review]. Stroke. 47(3):750-5, 2016 Mar.
51.	Hughes DC, Raghavan A, Mordekar SR, Griffiths PD, Connolly DJ. Role of imaging in the diagnosis of acute bacterial meningitis and its complications. Postgrad Med J. 2010;86(1018):478-485.
52.	Bykowski J, Kruk P, Gold JJ, Glaser CA, Sheriff H, Crawford JR. Acute pediatric encephalitis neuroimaging: single-institution series as part of the California encephalitis project. Pediatr Neurol. 2015;52(6):606-614.
53.	Wasay M, Kojan S, Dai AI, Bobustuc G, Sheikh Z. Headache in Cerebral Venous Thrombosis: incidence, pattern and location in 200 consecutive patients. J HEADACHE PAIN. 11(2):137-9, 2010 Apr.
54.	Kirk C, Nagiub G, Abu-Arafeh I. Chronic post-traumatic headache after head injury in children and adolescents. Dev Med Child Neurol. 2008; 50(6):422-425.
55.	Dayan PS, Holmes JF, Hoyle J Jr, et al. Headache in traumatic brain injuries from blunt head trauma. Pediatrics. 135(3):504-12, 2015 Mar.
56.	American College of Radiology. ACR Appropriateness Criteria® Radiation Dose Assessment Introduction. Available at: https://edge.sitecorecloud.io/americancoldf5f-acrorgf92a-productioncb02-3650/media/ACR/Files/Clinical/Appropriateness-Criteria/ACR-Appropriateness-Criteria-Radiation-Dose-Assessment-Introduction.pdf.

Disclaimer

The ACR Committee on Appropriateness Criteria and its expert panels have developed criteria for determining appropriate imaging examinations for diagnosis and treatment of specified medical condition(s). These criteria are intended to guide radiologists, radiation oncologists and referring physicians in making decisions regarding radiologic imaging and treatment. Generally, the complexity and severity of a patient’s clinical condition should dictate the selection of appropriate imaging procedures or treatments. Only those examinations generally used for evaluation of the patient’s condition are ranked. Other imaging studies necessary to evaluate other co-existent diseases or other medical consequences of this condition are not considered in this document. The availability of equipment or personnel may influence the selection of appropriate imaging procedures or treatments. Imaging techniques classified as investigational by the FDA have not been considered in developing these criteria; however, study of new equipment and applications should be encouraged. The ultimate decision regarding the appropriateness of any specific radiologic examination or treatment must be made by the referring physician and radiologist in light of all the circumstances presented in an individual examination.