It can be challenging to know which child with headaches should have imaging, just as it can be difficult to deny imaging when facing highly concerned parents and patients. Headaches occur in up to 75% of school-aged children.1 The chances of headache are greater in adolescents. Boys are more commonly affected in children younger than age 12 years, but girls are more likely to be affected among teenagers.1 Most headaches in children are primary and consist of migraine, tension type headache, trigeminal autonomic headache, and daily headache.1 Migraines and tension headaches are the two most common causes of headaches in children.1
Secondary headaches are a manifestation of an underlying illness and more common among children younger than age 5 years.2,3 There are seven distinct secondary headache entities: (1) traumatic headaches, (2) cranial or cervical vascular disorders, (3) nonvascular intracranial disorders, (4) substance use or withdrawal, (5) infections, (6) headache or facial pain attributed to disorder of cranium, neck, eyes, ears, nose, sinuses, teeth, mouth, and (7) psychiatric disorders.4 The prevalence of secondary headaches in children is 4% to 6%,2 and 72% are due to viral or upper respiratory infections.3
Several evidence-based clinical and radiology publications can support imaging decision in daily practice.
The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society developed a guideline that states explicitly that the routine use of neuroimaging is not indicated in children with recurrent headaches and a normal neurologic examination.5 On the contrary, “neuroimaging should be considered in children with an abnormal neurologic examination or other physical findings that suggest CNS disease.”5 Presence of clinical “red flag” criteria can indicate the use of neuroimaging.6
Headaches can raise concerns for an underlying neoplasm. The annual incidence of pediatric brain tumors in the United States, however, is only 0.005%.7 Less than 1% of patients have no additional symptoms, but if they do, 85% develop additional symptoms within 2 months.8
There is symptom overlap between primary headaches and sinus disease, due to similar anatomic autonomic involvements, such as involvement of the trigeminal nerve.9 Most patients who self-diagnose as having “sinus headaches” actually have migraines.9 Plain radiographs lack specificity for acute or chronic pediatric sinusitis and no longer play a role in sinus imaging.10 Pediatric sinusitis is diagnosed based on a set of clinical criteria, and the use of computed tomography (CT) or magnetic resonance imaging (MRI) is reserved for patients with clinical signs of complications such as orbital or central nervous system involvement.11
Postconcussive headaches often do not require routine imaging; however, if additional neurologic symptoms are present, imaging with MRI can be indicated.12 The use of imaging in the acute head trauma setting is informed by several clinical rules, notably a prospective study conducted by the Pediatric Emergency Care Applied Research Network that identifies children at low risk for brain injury who do not need brain imaging with a sensitivity of 100%.13
Regarding a possible cerebral aneurysm, the American Heart Association indicates using imaging in patients with two or more family members with known intracranial aneurysm or history of subarachnoid hemorrhage, or in patients with certain congenital disorders.14 The rupture rate for aneurysms larger than 2 mm is only 0.7%. Treatment may only be beneficial for aneurysms larger than 7 mm.15 Treatment complication rates are not negligible, with a 1-year morbidity of 9.8% and mortality of 2.3%.16
The American College of Radiology (ACR) Appropriateness Criteria provide excellent guidance regarding the use of imaging modalities and imaging techniques. Specific pediatric ACR Appropriateness Criteria exist for headache, sinus disease, and head trauma ( https://www.acr.org/Clinical-Resources/ACR-Appropriateness-Criteria). The most applicable to this article, ACR Appropriateness Criteria Headache-Child, is a great reference for what to order with which variant of symptoms and presentation.12
The radiologist's search pattern and differential considerations are concerned with (1) the general appearance including the brain parenchyma and ventricular system, (2) the position of the cerebellar tonsils, (3) the vascular system, and (4) other head and neck structures.
Stroke. Stroke is rare in children, but it can have atypical presentations compared to adults, including complaints of headache. Stroke can be readily diagnosed on MRI using a diffusion-weighted imaging sequence, which is routinely used in brain MRI examinations (Figure 1). Often, abbreviated or “rapid” MRI protocols can be performed to acutely diagnose the infarct and allow discussion for possible treatment options. Alternately, CT of the head and CT angiography of the head and neck can be performed if MRI is not immediately available.17
Magnetic resonance imaging (MRI) findings in a 14-year-old girl with right occipital infarction. MRI diffusion-weighted imaging (DWI) shows acute stroke 30 to 40 minutes after the event. (A) Stroke exhibits bright signal on DWI (arrow) with (B) a corresponding dark signal on a concomitantly calculated apparent diffusion coefficient map (arrow). (C) It may take a up to 4 hours before MRI signal changes are evident on other MRI images, such as fluid-attenuated inversion recovery, showing increased signal, sulcal effacement, and mild perifocal mass effect (arrow). (D) Noncontrast magnetic angiograms may be helpful in identifying underlying pathologies, such as occlusion of the right posterior cerebral artery in this patient (arrow).
New hydrocephalus. Hydrocephalus in children may be congenital or acquired, and common causes are primary aqueductal stenosis and other brain malformations, intraventricular cysts, sequelae of hemorrhage or infection, and obstructing brain tumors.18 The hallmark imaging sign of hydrocephalus is ventricular enlargement in the absence of cerebral atrophy (Figure 2).19
Imaging signs of hydrocephalus in a 12-year-old boy with new hydrocephalus after a diagnosis of meningitis. (A) Normal appearance of the brain on axial noncontrast computed tomography imaging at the initial presentation. (B) Subsequent enlargement of the ventricles (white arrow) and sulcal effacement (black arrow). (C) Additional signs of hydrocephalus are enlargement of the temporal horns (arrow) and (D) periventricular edema (arrow).
Tumor. Brain tumors are a rare finding in patients presenting with isolated headaches, seen in less than 1% of all children imaged for headaches (Figure 3).12 Although rare, it can understandably be the dominant concern from parents and providers for imaging in this symptomatic population.
Brain tumor in a 6-year-old boy with frequent headaches and ataxia with imaging diagnosis of diffuse intrinsic pontine glioma (DIPG). (A) The initial computed tomography scan showed a diffusely expansile hypodense mass within the brainstem (arrow) without (B) associated hydrocephalus (arrow) despite (C) mass effect on the fourth ventricle best seen on magnetic resonance imaging (MRI) sagittal T2 (arrow). (D) MRI confirmed imaging findings of DIPG, with only a small area of contrast enhancement (arrow).
Idiopathic intracranial hypertension. Headache is by far the most common symptom in idiopathic intracranial hypertension (IIH).15 Neuroimaging is an integral part of the diagnostic criteria for IIH, predominantly for excluding other pathologies in patients with papilledema, but also offering diagnostic signs in patients without papilledema (Figure 4).15
Magnetic resonance imaging (MRI) findings of idiopathic intracranial hypertension (IIH) in a 16-year-old girl with headaches and papilledema. The noncontrast MRI sagittal T1 images showed fluid causing expansion of the sella and (A) mass effect on the pituitary gland (arrow), sometimes making the pituitary gland almost imperceptible (“empty” sella). (B) A noncontrast magnetic resonance venogram showed right-sided stenosis of the transverse venous sinus (arrow). (C) Axial T2-weighted image shows flattening of the posterior globe as a sign of papilledema (black arrows) and peri-optic edema (white arrows).
Posterior reversible encephalopathy syndrome. This may occur in children with a variety of diagnoses, most notably those receiving immunosuppressant therapy for kidney transplant, children with severe hypertension, and children undergoing cancer treatment (Figure 5).20
Imaging findings in posterior reversible encephalopathy syndrome in an 8-year-old girl admitted for hypertensive crisis and headaches. (Top row) Axial noncontrast computed tomography images show (A) right greater than left subtle cerebellar arrow) and (B, C) cerebral hypodensities (arrows). (Bottom row) Noncontrast axial magnetic resonance imaging fluid-attenuated inversion recovery images (C, D, E) performed the same day better demonstrate the brain lesions as high-signal areas (arrows), including (E) a deep white matter lesion that was not well seen on computed tomography (arrow).
Position of the Cerebellar Tonsils
Chiari I. Patients with Chiari I malformation may have symptoms related to cerebrospinal fluid (CSF) circulation and symptoms related to compression or traction of the brainstem, cranial nerves, or cerebellar structures at the craniocervical junction.21 Classically, headaches in patients with Chiari I malformation are evoked by strain.21 The imaging criteria for Chiari I malformation are variable; they are sensitive but do not correlate well with severity of symptoms (Figure 6).21
Magnetic resonance imaging (MRI) findings in Chiari I malformation in a 5-year-old boy with headaches. The initial MRI sagittal T2 images (A) of the craniocervical junction and cervical spine showed low position of the cerebellar tonsil relative to the foramen magnum and pointed configuration of the tip of the tonsils (black arrow). A small syrinx is found in the cervical spinal cord (white arrow). (B) A cerebrospinal fluid (CSF) flow study revealed diminished flow across the posterior craniocervical junction (arrow). (C) Postoperatively, the CSF spaces at the craniocervical junction are restored (black arrow) and the cervical syrinx is almost resolved (white arrow).
Intracranial hypotension. A differential consideration for low-lying cerebellar tonsil is intracranial hypotension, which may also present with headaches but for which clinical presentation and imaging criteria differ significantly from Chiari I malformation. A typical clinical presentation is headaches that are exacerbated by an upright body position (Figure 7).22 The cause of intracranial hypotension is usually a spinal CSF leak, and, therefore, spine imaging for detecting leaks such as CT or magnetic resonance myelography can prove useful.22
Magnetic resonance imaging (MRI) findings in an 18-year-old male with leukemia, trauma, and subsequent intracranial hypotension. (A) Normal appearance of the brain structures on the initial MRI sagittal T1. (B) After the patient experienced a trauma, he developed a low-pressure headache, and the MRI sagittal T1-weighted image shows descent of the cerebellar tonsils relative to the foramen magnum (white arrow) and compression of the interpeduncular fossa (black arrow). (C) Postcontrast sagittal T1-weighted image shows diffuse venous engorgement involving the superior sagittal sinus and pituitary gland (white arrows), as well as (D) diffuse dural thickening and enhancement (ie, pachymeningitis) (arrows).
Cerebral sinovenous thrombosis This is a rare but serious diagnosis with increased intracranial pressure due to obstruction of venous outflow.23 Among risk factors for pediatric cerebral sinovenous thrombosis are head and neck infections and diseases with coagulopathies or a disturbed systemic circulation (Figure 8).23
Imaging findings of cerebral sinus venous thrombosis in a 16-year-old girl with headaches. (A) The initial noncontrast computed tomography sagittal reformat shows a hyperdense thrombus in the straight venous sinus (black arrow) and the vein of Galen (white arrow). (B) Subsequent magnetic resonance imaging shows corresponding filling defects on postcontrast sagittal T1 (arrows). (C) The patient had developed infarctions in the right thalamus (white arrow) and the splenium of the corpus callosum (black arrow). (D) A noncontrast venogram showed lack of flow-related signal in the straight venous sinus (black arrow) and the vein of Galen (white arrow).
Vascular malformations. Arteriovenous malformations (AVM) may present with an acute hemorrhage in about one-half of patients (Figure 9).24 AVM is a major differential consideration for nontraumatic intracranial bleeds in children. Cavernous malformation is another benign vascular lesion and may go undetected unless intracranial bleeding or hemorrhagic stroke occur (Figure 9).24
Imaging appearance of vascular malformations in a 12-year-old boy with sudden onset headaches and arteriovenous malformation (AVM). (A) Intraparenchymal bleed on axial noncontrast head computed tomography (CT) images (arrow) raised concern for an AVM. (B) Postcontrast CT arterial-phase images show a tangle of vessels (white arrow) and a large draining vein (black arrow), which are typical features of AVM. (C, D) A 17-year-old girl with worsening headaches and cavernous malformation. (C) Hyperdense lesion in the brainstem on axial noncontrast head CT images (arrow) raised concern for a bleed. (D) Subsequent magnetic resonance imaging sagittal T2 image shows imaging signs of a cavernous malformation with recent hemorrhage (arrow).
Hemiplegic migraine. The diagnosis of hemiplegic migraines can typically be made based on the clinical history and examination.25 Differential considerations include stroke, vasculitis, infection, mitochondrial syndromes, cerebral autosomal-dominant arteriopathy with subcortical infarcts and leukoencephalopathy, and transient headache and neurological deficits with cerebrospinal fluid lymphocytosis.25 MRI findings in hemiplegic migraines reflect abnormal states of cerebral perfusions, such as initial vasoconstriction with hypoperfusion, followed by vasodilatation with hyperperfusion (Figure 10).
Magnetic resonance imaging (MRI) findings in a 17-year-old girl with hemiplegic migraine. Axial MRI susceptibility-weighted angiogram shows engorged cerebral veins of the left cerebral hemisphere in the setting of hyperperfusion (arrow).
Head and Neck
Enlarged adenoids. Enlarged adenoids can cause airway obstruction and sleep apnea or otitis media, which can be associated with headaches.26 The diagnosis of adenoidal enlargement is made via nasal endoscopy, but in uncooperative children imaging can serve the purpose of documenting necessity for surgery.27 A single lateral view of the neck can readily evaluate for enlarged adenoids and resultant narrowing of the nasopharyngeal airway.
Sinusitis. The diagnosis of sinusitis remains a clinical one, unless there is suspicion for neurologic symptoms, which are concerning for intracranial extension of infection. ACR appropriateness criteria have been created to help guide appropriate imaging of suspected sinus infection.28
Temporomandibular joint arthritis. Juvenile idiopathic arthritis has a high predilection for temporomandibular joint arthritis and can cause headache, neck pain, and jaw dysfunction.29
Orbit abnormalities. Abnormalities of the globe can be detected on routine brain imaging given typical inclusion of the orbits on a routine head CT or MRI. Abnormalities of the globe or orbital pathway can be seen with many diagnoses, including myopia and glaucoma, both of which are associated with headaches.30
Pediatric headaches are common and the vast majority do not require imaging. Several evidence-based guidelines can assist practitioners in using imaging in the most effective way, but there still remain numerous barriers to implementing evidence-based guidelines in daily practice. Imaging plays a major role in establishing diagnoses in patients with secondary headaches.
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- International Headache Society. International Classification of Headache Disorders (ICHD-3). Accessed August 19, 2020. https://ichd-3.org/.
- Alp R, Alp SI, Palanci Y, et al. Use of the International Classification of Headache Disorders, second edition, criteria in the diagnosis of primary headache in schoolchildren: epidemiology study from eastern Turkey. Cephalalgia. 2010;30(7):868–877. doi:10.1177/0333102409355837 [CrossRef] PMID:20647179
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- Johnson KJ, Cullen J, Barnholtz-Sloan JS, et al. Childhood brain tumor epidemiology: a brain tumor epidemiology consortium review. Cancer Epidemiol Biomarkers Prev. 2014;23(12):2716–2736. doi:10.1158/1055-9965.EPI-14-0207 [CrossRef] PMID:25192704
- Honig PJ, Charney EB. Children with brain tumor headaches. Distinguishing features. Am J Dis Child. 1982;136(2):121–124. doi:10.1001/archpedi.1982.03970380033008 [CrossRef] PMID:7064925
- Kirsch CFE. Headache caused by sinus disease. Neuroimaging Clin N Am. 2019;29(2):227–241. doi:10.1016/j.nic.2019.01.003 [CrossRef] PMID:30926113
- Wyler B, Mallon WK. Sinusitis update. Emerg Med Clin North Am. 2019;37(1):41–54. doi:10.1016/j.emc.2018.09.007 [CrossRef] PMID:30454779
- Wald ER, Applegate KE, Bordley C, et al. American Academy of Pediatrics. Clinical practice guideline for the diagnosis and management of acute bacterial sinusitis in children aged 1 to 18 years. Pediatrics. 2013;132(1):e262–e280. doi:10.1542/peds.2013-1071 [CrossRef] PMID:23796742
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- Thompson BG, Brown RD Jr, Amin-Hanjani S, et al. American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, and Council on Epidemiology and PreventionAmerican Heart AssociationAmerican Stroke Association. Guidelines for the management of patients with unruptured intracranial aneurysms: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2015;46(8):2368–2400. doi:10.1161/STR.0000000000000070 [CrossRef] PMID:26089327
- Rogers DL. A review of pediatric idiopathic intracranial hypertension. Pediatr Clin North Am. 2014;61(3):579–590. doi:10.1016/j.pcl.2014.03.004 [CrossRef] PMID:24852154
- Williams LN, Brown RD Jr, . Management of unruptured intracranial aneurysms. Neurol Clin Pract. 2013;3(2):99–108. doi:10.1212/CPJ.0b013e31828d9f6b [CrossRef] PMID:23914319
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