Pediatric Headache - When to Image

​Pediatric headaches with concurrent symptoms are to be taken seriously, and in some instances, imaging is strongly recommended. When determining whether to refer a patient for diagnostic imaging, consider if the patient has the following:

• Abnormal neurological exam
• Thunderclap headache pattern – first or worst headache
• Immunocompromised
• Absence of family history
• Atypical features (age of onset < 6 years, etc.)
• Refractory headache
• Headache waking patient from sleep, major exertional or positional changes
• Occipital headaches
• Confusion, mental changes, seizures

When referring a patient to imaging, there are four common diagnostic options that look for different concerns in the brain.

• CT scan: major abnormalities, bleeds
• Rapid
• More commonly available
• MRI: posterior fossa
• Much more detailed
• More sensitive for vascular- or infection-neoplasm
• Bright nonspecific T2 foci common in frequent migraines (sometimes even in general population)
• MRA: occlusion, vasculitis, RCVS, aneurysms, AVMS, etc.
• MRV: sinus venous thrombosis, signs of high intracranial pressure (transverse sinus obliteration, sometimes congenital variants)