Pediatric emergency medicine trisk 1153 1153

associated with the administration of contrast material. However, obtaining a
nonemergent MRI from the ED may not be an available option. What then is the
appropriate diagnostic approach? Certainly, having a clinical pathway in place
may be helpful for arranging efficient and timely outpatient care.
In general, a child with headaches who is suspected of having a brain tumor
should undergo a head CT scan in the ED if there are any signs or symptoms of
elevated ICP or mass effects. These include an altered mental status, visual
changes, persistent vomiting, papilledema, or focal neurologic deficits. Because
tumors that cause elevated ICP or mass effects are usually larger and more easily
detectable, the reduction in image resolution with CT is less likely to result in
missing an abnormality in such cases. Of note, if the CT scan is normal in a child
with headache and new focal deficits on neurologic examination, it may be
necessary to obtain an emergent MRI to exclude the diagnosis of stroke (e.g.,
arterial dissection), although this may simply represent the first presentation of a
complex migraine syndrome.
But what about the child with a suspicious history (e.g., increasing frequency
or duration of pain, headaches that awaken the child from sleep or occur every
morning) who has a normal neurologic examination and no signs of elevated
ICP? In most cases, if MRI is not available for a nonemergent scan from the ED,
such patients can be safely discharged with an outpatient MRI scheduled shortly
thereafter. In such cases, parents must be clearly instructed that any sign of
deterioration, such as mental status changes or persistent vomiting, requires that
the child be immediately returned to the ED for a reevaluation.
Suggested Readings and Key References
Brna PM, Dooley JM. Headaches in the pediatric population. Semin Pediatr
Neurol 2006;13(4):222–230.
de Ribaupierre S, Rilliet B, Cotting J, et al. A 10-year experience in paediatric
spontaneous cerebral hemorrhage: which children with headache need more
than a clinical examination? Swiss Med Wkly 2008;138(5–6):59–69.
Genizi J, Khourieh-Matar A, Assaf N, et al. Occipital headaches in children: are
they a red flag? J Child Neurol 2017;32(11):942–946.

Expert Panel on Pediatric Imaging; Hayes LL, Palasis S, Bartel TB, et al. ACR
Appropriateness Criteria® headache—child. J Am Coll Radiol
2018;15(5S):S78–S90.
Hershey AD. Pediatric headache. Pediatr Ann 2005;34:426–429.
Honig PJ, Charney EB. Children with brain tumor headaches: distinguishing
features. Am J Dis Child 1982;136:121–141.