Pediatric emergency medicine trisk 1152 1152

capacity, limited availability continues to be the main drawback of MRI. Even
when the MRI is available, children may require deep sedation under the
supervision of an anesthesiologist. This makes nonemergent MRI scans difficult
to obtain from the ED, even in large institutions. As discussed in the following,
the emergency physician must take these and other factors into account in
determining which, if any, imaging modality is indicated for a child with
headaches.

Treatment and Disposition
Patients with headaches caused by a potentially life-threatening process (e.g.,
meningitis, encephalitis, ruptured vascular anomaly) require specific treatment
approaches discussed elsewhere in this textbook. A patient with idiopathic
intracranial hypertension may require drainage of CSF to reduce the ICP, which,
in turn, often relieves the headache. Children with headaches that are
presumptively diagnosed as benign can often be successfully treated with
acetaminophen or ibuprofen. It is important to treat and not underestimate the
pain the child may be experiencing. Nerve blocks are also being studied as a
potential treatment option for primary headaches. The various options available
for treating pediatric migraine patients are described in Chapter 97 Neurologic
Emergencies .
Although most children complaining of headache can be safely discharged
from the ED with an appropriate follow-up plan, some will require admission to
the hospital for further evaluation and treatment. For example, a child with
headaches who is found to be significantly hypertensive must be admitted both
for management of the blood pressure and investigation of the underlying cause.
Any patient with idiopathic intracranial hypertension who also has decreased
visual acuity requires emergent evaluation by an ophthalmologist and possibly a
surgical procedure to relieve the pressure on the optic nerve. Patients with
migraine who have intractable headache may also warrant admission for more
effective analgesia. The child with a ventricular shunt who has severe headaches
will usually require a shunt series, a CT scan of the head, and neurosurgical

evaluation to assess the need for possible shunt revision. If neurosurgical
consultation is not immediately available, the patient should be transported to an
appropriate receiving facility.
A potentially confusing issue that the emergency physician will inevitably face
is how to properly manage a child who is suspected of having a brain tumor.
Should all these patients have a brain imaging study in the ED? As discussed
previously, the resolution of even a contrast-enhanced head CT scan is inferior to
MRI for detecting certain types of tumors. Also, a small but finite risk is