Acute headache in children and adolescents presenting to the emergency department

Clinical Characteristics and Appropriateness of Investigations in Children With Headaches at the Emergency Department

BACKGROUND

Identifying the cause of headaches in pediatric emergency departments (PEDs) can be challenging due to the lack of comprehensive research. This study aims to identify the frequency, characteristics, and unnecessary diagnostic procedures of patients with headaches in the PED setting.

METHODS

A six-month cross-sectional study was conducted at the PED of Alexandria University Children's Hospital, including all children with headaches. Children were classified as having primary headache (PH), secondary benign headache (SBH), and secondary serious headache (SSH) according to predetermined criteria. Logistic regression was employed to analyze the risk factors associated with SSH.

RESULTS

A total of 164 visits to the PED were recorded, out of a total of 22,662 visits, accounting for approximately 0.72% of all visits and 1.17% of the total number of children admitted. PH was the most common cause, accounting for 61.0% of cases, followed by SSH with 24.4%, whereas SBH was the least common with 13.4%. Abnormal neurological examination (odds ratio, 53.752 [1.628 to 1774.442], P = 0.026∗) was found to have a strong and statistically significant association with SSH in the multivariate analysis. Regarding the appropriateness of the investigations conducted, it was found that over half (66.5%) of the cases had unnecessary neuroimaging, with 52% of these cases being children with PH.

CONCLUSIONS

Headaches in children are commonly reported during visits to the PED. PH was the most prevalent, followed by SSH, whereas SBH was the least common. Many of the children received inaccurate first diagnoses and performed unnecessary laboratory tests, neuroimaging, and other tests, mostly electroencephalography.

Stratification of risk for emergent intracranial abnormalities in children with headaches: a Pediatric Emergency Care Applied Research Network (PECARN) study protocol

INTRODUCTION

Headache is a common chief complaint of children presenting to emergency departments (EDs). Approximately 0.5%-1% will have emergent intracranial abnormalities (EIAs) such as brain tumours or strokes. However, more than one-third undergo emergent neuroimaging in the ED, resulting in a large number of children unnecessarily exposed to radiation. The overuse of neuroimaging in children with headaches in the ED is driven by clinician concern for life-threatening EIAs and lack of clarity regarding which clinical characteristics accurately identify children with EIAs. The study objective is to derive and internally validate a stratification model that accurately identifies the risk of EIA in children with headaches based on clinically sensible and reliable variables.

METHODS AND ANALYSIS

Prospective cohort study of 28 000 children with headaches presenting to any of 18 EDs in the Pediatric Emergency Care Applied Research Network (PECARN). We include children aged 2-17 years with a chief complaint of headache. We exclude children with a clear non-intracranial alternative diagnosis, fever, neuroimaging within previous year, neurological or developmental condition such that patient history or physical examination may be unreliable, Glasgow Coma Scale score<14, intoxication, known pregnancy, history of intracranial surgery, known structural abnormality of the brain, pre-existing condition predisposing to an intracranial abnormality or intracranial hypertension, head injury within 14 days or not speaking English or Spanish. Clinicians complete a standardised history and physical examination of all eligible patients. Primary outcome is the presence of an EIA as determined by neuroimaging or clinical follow-up. We will use binary recursive partitioning and multiple regression analyses to create and internally validate the risk stratification model.

ETHICS AND DISSEMINATION

Ethics approval was obtained for all participating sites from the University of Utah single Institutional Review Board. A waiver of informed consent was granted for collection of ED data. Verbal consent is obtained for follow-up contact. Results will be disseminated through international conferences, peer-reviewed publications, and open-access materials.

How Can Specialist Advice Influence the Neuroimaging Practice for Childhood Headache in Emergency Department?

Differentiating between primary and secondary headaches can be challenging, especially in the emergency department (ED). Since symptoms alone are inadequate criteria for distinguishing between primary and secondary headaches, many children with headaches undergo neuroimaging investigations, such as brain CT and MRI. In various studies, the frequency of neuroimaging utilization is influenced by several factors, including teaching status, ownership, metropolitan area, insurance status, and ethnicity of patients. However, only a few studies have considered the role of specialist consultations in ordering neuroimaging studies on childhood headaches. We report the contributions of different specialists to the evaluation of children with headaches admitted to the ED and their influence on neuroimaging decisions. We retrospectively reviewed the medical reports of paediatric patients who presented with headaches to the paediatric ED of the Ospedale Maggiore Policlinico of Milano between January 2017 and January 2022. Overall, 890 children with headaches were evaluated (mean age: 10.0 years; range: 1 to 17 years). All patients were examined by the ED paediatricians, while specialist consultations were required for 261 patients, including 240 neurological (92.0%), 46 ophthalmological (17.6%), and 20 otorhinolaryngological (7.7%) consultations. Overall, 173 neuroimaging examinations were required, of which 51.4 and 48.6% were ordered by paediatricians and neurologists, respectively. In particular, paediatricians required 61.4% of brain CT scans, and neurologists required 92.0% of brain MRI scans. In conclusion, paediatricians were responsible for the management of most children with headaches admitted to the ED, while specialist consultations were required only in about a third of the cases. Although there was no significant difference in the number of neuroimaging studies ordered by specialists, brain CT scans were most often used by paediatricians, and MRI scans by neurologists.

Management and behavior-modifying recommendation effects in childhood headache

BACKGROUND

Headaches are common in childhood. Recently, there has been an increasing trend toward pharmacological treatment.

METHODS

Secondary causes were excluded first in patients who attended our clinic with headache. Those without a secondary cause were evaluated as primary headache and classified into subgroups. Behavior-modifying recommendations (adequate and regular sleep, adequate and regular nutrition, adequate fluid intake, and restriction of screen exposure) were given to all patients. Patients were re-evaluated at 1, 3, and 6 months. Pharmacologic treatment was started at the end of the first month with follow-up at the third and sixth months for those who did not benefit from the behavior-modifying recommendations.

RESULTS

A total of 875 patients presented with headache complaints, of which 30.6% were evaluated as primary headache. Behavior-modifying recommendations were beneficial for 23.1% with migraine with aura; 20.3% with migraine without aura, and 36.8% with tension-type headache.

CONCLUSION

Secondary causes should be excluded first in patients who present to the pediatric neurology clinic with headache. Behavioral modifications to change the lifestyle of patients diagnosed with primary headache should be tried before giving pharmacologic treatment.

Impact of COVID-19 Pandemic on Headache Evaluations in the Pediatric Emergency Department

BACKGROUND

To evaluate the impact of COVID-19 on evaluations in the pediatric emergency department (ED) because of headache as main symptom.

METHODS

Number and clinical features of patients evaluated in the pediatric ED of a single site in Milan, Italy, were collected between January 2017 and January 2022. The impact of COVID-19 on evaluation rates was quantified by using the incidence rate ratio (IRR) and 95% confidence intervals (CI) between the pandemic (March 2020 to January 2022) and the prepandemic period (January 2017 to February 2020).

RESULTS

During the study period, 890 evaluations were registered: 689 over the prepandemic period and 201 over the pandemic period. Mean age at evaluation was 10 years (range: 1 to 17 years). Evaluation rates per month were 18.1 during the prepandemic period and 8.7 during COVID-19 pandemic, with peaks in autumn and winter months and considerable drops in the summer. The IRR was 0.49 (95% CI, 0.40-0.61). The reduction in evaluation rate was higher for secondary headache (IRR, 0.31; 95% CI, 0.23-0.42) when compared with primary headache (IRR, 0.56; 95% CI, 0.40-0.78).

CONCLUSIONS

We found a remarkable reduction in the number of evaluations in the pediatric ED for headache during the pandemic period.

The diagnostic values of red flags in pediatric patients with headache

BACKGROUND

Headache is a common complaint in childhood and adolescence. Differentiating benign primary headaches from ominous secondary headaches is often difficult. Clinicians usually seek red flags to determine the need for neuroimaging. We aimed to evaluate the diagnostic values of red flags in pediatric headaches.

METHODS

We retrospectively reviewed the medical records of 1510 pediatric patients (1470 with primary headache, 40 with secondary headache) presenting with headache and underwent neuroimaging from two centers between March 2010 and December 2019.

RESULTS

The secondary-headache group exhibited significantly higher frequencies of abnormal neurologic signs/symptoms (40.0% vs 6.8%, p < 0.001), Valsalva maneuver/exercise-induced headache (15.0% vs 4.9%, p = 0.004), headache with vomiting (35.0% vs 17.9%, p = 0.006), and onset under age 6 (25.0% vs 10.3%, p = 0.003) than the primary-headache group, with the following positive likelihood ratio (PLR): 5.88, 3.06, 1.96, and 2.42, respectively. The sensitivity values were as follows: abnormal neurologic signs/symptoms (16/40, 40.0%), headache with vomiting (14/40, 35.0%), onset under age 6 (10/40, 25.0%), and Valsalva maneuver/exercise-induced headache (6/40, 15.0%). The overall sensitivity for ominous secondary headaches requiring surgical treatment was 86.2% (25/29).

CONCLUSIONS

Certain red flags, including abnormal neurologic signs/symptoms, Valsalva maneuver/exercise-induced headache, headache with vomiting, and onset under age 6, were more prevalent in the secondary-headache group; nonetheless, their sensitivity values and PLR were relatively low. Notwithstanding, considering these red flags' high overall sensitivity for ominous secondary headaches, neuroimaging in patients presenting these red flags should rely on careful follow-up of symptom progression.

Headache in the Pediatric Population: Focus on Migraine

Pediatric headache is a common condition with significant impact on quality of life and ability to function in academic, social, and extracurricular activities. Most pediatric patients seen in primary care and neurology clinics with headache have primary headache disorders. Diagnosis is largely based on clinical history. Imaging is rarely needed in the absence of red flag features. Careful diagnosis is important to guide appropriate treatment. Treatment focuses on a biopsychosocial model integrating lifestyle, pharmacologic and nonpharmacologic treatment modalities. As few therapies are approved in the pediatric population, treatments are often used off-label based on evidence extrapolated from adult studies. Outcomes vary over time but are generally favorable when headache disorders are diagnosed promptly and managed in a multidisciplinary setting.

Retrospective Evaluation of Acute Headache in Pediatric Emergency Department: Etiologies, Red Flags, and Neuroimaging

BACKGROUND

The aims of this study were to describe the etiologies of acute headache presenting to the pediatric emergency department, determine their clinical characteristics, the prevalence of red flag findings and neuroimaging and identify predictors of headaches because of serious intracranial diseases.

MATERIALS AND METHODS

Patients from 2 to 18 years of age who visited pediatric emergency department with a chief complaint of headache between January 1, 2016 and August 31, 2020 were retrospectively evaluated.

RESULTS

The mean age of the 558 patients included in the study was 11.17±3.78 years, and 290 (52%) were female. The most common cause of acute headache was head and neck area infections (except central nervous system infections) in 355 (63.6%) patients. Forty patients (7.2%) had a headache because of serious intracranial diseases. According to binary logistic regression analysis, the findings that predicted a serious intracranial diseases were abnormal neurological physical examination [odds ratio (OR): 187.57; 95% confidence interval (CI): 32.67-1076.64], recent onset or suddenly severe headache (OR: 14.41; 95% CI: 3.14-65.91), and vomiting (OR: 9.42; 95% CI: 1.90-46.63). Neuroimaging was performed in 63 (11.3%) patients, and 7 (1.25%) had a pathology requiring emergency treatment.

CONCLUSIONS

The majority of acute headaches were evaluated as secondary headache. The most common cause of acute headache was head and neck area infections. Abnormal neurological physical examination, recent onset or suddenly severe headache, and vomiting were the most useful red flags for predicting serious intracranial diseases. The requirement for neuroimaging should be evaluated individually for each patient.

Epidemiology of Headache in Children in a Community Emergency Department: A Scoping Study

OBJECTIVE

This study aimed to describe the epidemiology of headache in children attending a community mixed adult-pediatric emergency department (ED) in Australia with a view to providing scoping data for future headache-related projects for the pediatric ED research networks.

METHODS

This is a retrospective cohort study by medical record review. Participants were children aged 2 to 16 years who presented to the ED between January 1, 2016, and December 31, 2016, with a major symptom of headache. Exclusion criteria were a history of recent head trauma, a ventriculoperitoneal shunt in situ, or known intracranial conditions associated with headache. Data collected included demographics, clinical features, investigations, diagnosis, disposition, and outcome. The primary outcomes of interest were the proportion of children with a serious ED diagnosis, the distribution of ED diagnoses, investigation ordering patterns, treatments provided, and clinical outcome.

RESULTS

A total of 225 children were studied, with a median age of 9 years (interquartile range, 6-13 years). The most common associated symptoms were fever (47%) and vomiting (42%). The most common examination feature was fever (21%). Abnormal neurological findings were very uncommon. Few children underwent advanced neuroimaging (7 patients; 3%), and no intracranial abnormalities were detected. Seven children had a serious diagnosis (7/225 [3%]; 95% confidence interval, 2%-6%). Six of these 7 were viral meningitis, and there was 1 case of bacterial meningitis.

CONCLUSIONS

In a community teaching hospital cohort of children with headache, intercurrent viral illness is the most common cause. Serious causes were very uncommon. The rate of bacterial meningitis, tumor, or abscess was <1%. This has implications for the planning of research projects.

Efficacy of a pediatric headache infusion center: A single-center experience

OBJECTIVE

To evaluate the efficacy of a pediatric headache infusion center (HIC) in alleviating the symptoms and preventing future visits to the emergency department (ED).

BACKGROUND

Headache is a common reason for visits to the pediatric ED. ED visits are associated with inordinate costs of care and are conceived by parents to be avoidable if adequate alternatives are available. An infusion center for acute treatment of intractable headache in children with chronic migraine may be an effective alternative to an ED visit.

METHODS

This was a retrospective analysis of data from a single-center cohort of patients with a known history of chronic migraine, presenting to Dayton Children's HIC with an acute migraine from June 1, 2017 to June 1, 2020. Patients were treated according to established protocols divided into two pathways. Patient demographics, clinical characteristics, pre- and postinfusion pain scores, ED visits and inpatient admissions within 2 weeks of HIC visit, and ED visits 1 year prior and 1 year after the HIC visit were noted.

RESULTS

A total of 297 HIC visits were analyzed from 201 patients. The HIC was effective in controlling symptoms with a significant reduction in pain score (median [interquartile range; IQR] 7.0 [2.0] preinfusion vs. 1.0 [2.0] postinfusion, p < 0.001). Only 25/297 (8.4%) patients came to the ED within 2 weeks of the HIC visit, and an even smaller number of patients (20/297, 6.7%) were admitted as inpatients within 2 weeks of the HIC visit. The number of ED visits was significantly reduced in the year after the HIC visit compared with the year prior (median [IQR] 1.0 [2.0] before vs. 0.0 [1.0] after, p < 0.001).

CONCLUSION

A pediatric HIC is effective in alleviating the symptoms and preventing ED visits. These centers should be considered as standard of care at children's hospitals.

Pediatric headache: Are the red flags misleading or prognostic?

BACKGROUND

Symptoms and findings called orange or red flags may indicate the etiology of pediatric headaches and may point to a life-threatening situation requiring urgent treatment and thus can alter patient management. These findings can be either misleading or prognostic for clinicians. We aimed to identify the etiology and prognostic value of orange/red flags in pediatric patients.

METHODS

This study included 810 children with headaches who underwent neuroimaging due to the existence of orange/red flags. Their hospital records were examined to obtain demographical, clinical, laboratory data, and re-classify the headaches and determine orange/red flags on admission.

RESULTS

Secondary causes were identified in 17.0% (n: 138) of patients, however, those who were diagnosed with a life-threatening headache that required emergency treatment were 5.2% of all patients and 30.4% of the patients diagnosed with a secondary headache. Those with secondary headaches and with life threatening secondary headaches which required urgent treatment were younger (p = 0,018, p = 0,022), had more emergency department visits (p < 0,001), and acute onsets (p < 0,001). Red flags, like systemic symptoms (p < 0,001), sudden onset (p = 0,023, p = 0.039), papilledema (p < 0,001), and progressive headaches (p = 0,048, p = 0.006), were more common with secondary headaches and its subgroup, while headache awakening from sleep (p = 0.009) and family history of primary headache (P > 0,001) were more common in primary headaches. No correlation existed between the number of red flags and etiology. However, older age (p = 0,001) and a shorter duration between symptoms and admission (p = 0,032), and the number of emergency service visits (p = 0,020) increased with increasing red flags.

CONCLUSIONS

Physicians always look for flags when they encounter patients with headaches, which is a common symptom, so as not to overlook anything. However, red flags do not always mean that the underlying cause requires emergency treatment and the severity of the cause is not correlated with the number of flags.

Diagnosis and Treatment of Headache in a Pediatric Emergency Department

OBJECTIVES

The aims of the study were (1) to analyze the etiology and clinical management of headaches in children in the emergency department and (2) to analyze the treatment used in children diagnosed with headaches and with migraines.

METHODS

Retrospective study of all the patients who were admitted to the pediatric emergency department of Hospital Professor Doutor Fernando Fonseca, Lisbon, in 2014, with a chief complaint of headaches or the primary discharge diagnosis was headache/migraine.

RESULTS

Headache related cases represented 3.8% of all the visits, a total of 2354 subjects. The median age was 10 years and 52.6% were female. The most frequent diagnoses were as follow: headaches (21.3%), upper respiratory infections (18.4%), and migraines (6.1%). There were 4 cases of meningitis, 6,5% of all patients underwent computed tomography which was mostly requested in school-age children and adolescents. The average time from the first medical observation until discharge was 85 minutes. Fifty-five percent did not take any pain relief medication, 17.2% took acetaminophen, and 11.1% took ibuprofen. Patients who received ondansetron had less revisits (P = 0.000). Subjects with mild-moderate pain treated with acetaminophen or no medication had more revisits (P = 0.000).

CONCLUSIONS

Secondary benign headaches were the most common and very rarely headache as a symptom was associated with life-threatening situations. Antiemetics seem to be efficient ally in the treatment of primary headaches, but it is important to consider alternative pharmacological regimes in patients who present with higher pain scores.

Clinical Factors Associated With Pediatric Brain Neoplasms Versus Primary Headache: A Case-Control Analysis

OBJECTIVE

Pediatric headaches are a common presentation to emergency departments accounting for almost half a million annual visits. Providers are left with the difficult task of deciding who has a secondary headache etiology that warrants neuroimaging.

METHODS

We conducted a retrospective case-control study. Patients from a pediatric neuro-oncology clinic database with brain cancer and a headache at presentation were identified as cases. Controls were patients from 2 local pediatric tertiary care emergency departments with a final diagnosis of headache after negative neuroimaging. Clinical factors were decided a priori, and logistic regression was used to determine which clinical factors were related to case/control status.

RESULTS

A total of 334 patients (203 controls and 131 cases) were included. Patients with a history of headaches had 0.5 (95% confidence interval [CI]: 0.3-0.9; P = 0.03) times the odds of being a case. Patients with vomiting had increased odds of being a case compared with controls regardless of the time of day (early morning 1.8 [95% CI: 1.0-3.2; P = 0.04] and non-early morning 6.6 [95% CI: 2.0-21.7; P < 0.01]). Patients with neurological signs had 10.3 (95% CI: 5.4-19.4; P < 0.01) times the odds of being a case, and patients with an associated seizure had 10.9 (95% CI: 3.8-30.7; P < 0.01) times the odds of being a case.

CONCLUSIONS

This study identified clinical factors associated with pediatric brain neoplasms that may guide acute neuroimaging decisions. This study also provides insight into potential clinical factors to be studied prospectively to derive a clinical decision rule.

Interobserver Agreement in the Assessment of Clinical Findings in Children with Headaches

OBJECTIVE

To determine the interobserver agreement of history and physical examination findings in children undergoing evaluation in the emergency department (ED) for headaches.

STUDY DESIGN

We conducted a prospective, cross-sectional study of children aged 2-17 years evaluated at 3 tertiary-care pediatric EDs for non-traumatic headaches. Two clinicians independently completed a standardized assessment of each child and documented the presence or absence of history and physical examination variables. Unweighted κ statistics were determined for 68 history and 24 physical examination variables.

RESULTS

We analyzed 191 paired observations; median age was 12 years, with 19 (9.9%) children younger than 7 years. Interrater reliability was at least moderate (κ ≥ 0.41) for 41 (60.3%) patient history variables. Eleven (61.1%) of 18 physical examination variables for which κ statistics could be calculated had a κ that was at least moderate.

CONCLUSIONS

A substantial number of history and physical examination findings demonstrated at least moderate κ statistic values when assessed in children with headaches in the ED. These variables may be generalizable across different types of clinicians for evaluation of children with headaches. If also found to predict the presence or absence of emergent intracranial abnormalities, the more reliable clinical findings may be helpful in the development of clinical prediction rules or risk stratification models that could be used across settings for children with headaches.

Family Perspectives on Visiting the Pediatric Emergency Department for Migraine: A Qualitative Study

OBJECTIVE

The aim of this study was to explore the perspectives of families regarding their expectations and experience of visiting the emergency department (ED) for migraine.

METHODS

This was a qualitative study involving the families of 25 patients aged 10 to 18 years receiving ED care for acute migraine. Following their visit, independent semistructured telephone interviews were conducted with both the patient and parent or guardian. Questions were designed to explore factors pertaining to the family's perspective regarding their visit to the ED and expectations for the ED visit.

RESULTS

Families reported a variety of reasons for visiting the ED. The majority of participants reported that they were worried about their headaches. Families more commonly had expectations for treatment than they did for investigations. As compared with patients, parents more commonly reported specific expectations for investigations and less commonly expressed concerns about intravenous treatments. Expectations for treatment efficacy varied: whereas some parents expected complete pain relief, for others, lesser degrees of relief were considered satisfactory. The experience of treatment efficacy was related to willingness to receive the same treatment again.

CONCLUSIONS

Given that a high frequency of families endorsed that they were worried about the headache when presenting to the ED, clinicians should strive to make a diagnosis of migraine in the ED setting and to educate families about this diagnosis. Because of divergent parent and patient perspectives, health care providers should inquire about family expectations, especially in relation to expectations for investigations and concerns surrounding intravenous interventions, and ensure that both the patient's and parent's perspectives are considered when developing a management plan for pediatric migraine.

Inpatient Management of Migraine

Migraine is a frequently disabling neurologic condition which can be complicated by medication overuse headache and comorbid medical disorders, including obesity, anxiety and depression. Although most migraine management takes place in outpatient clinics, inpatient treatment is indicated for migraine refractory to multiple outpatient treatments, with intractable nausea or vomiting, need for detoxification from medication overuse (such as opioids and barbiturates), and significant medical and psychiatric disease. The goals of inpatient treatment include breaking the current cycle of headache pain, reducing the frequency and/or severity of future attacks, monitored detoxification of overused medications, and reducing disability and improving quality of life.

Management of Childhood Headache in the Emergency Department. Review of the Literature

Headache is the third cause of visits to pediatric emergency departments (ED). According to a systematic review, headaches in children evaluated in the ED are primarily due to benign conditions that tend to be self-limiting or resolve with appropriate pharmacological treatment. The more frequent causes of non-traumatic headache in the ED include primitive headaches (21.8–66.3%) and benign secondary headaches (35.4–63.2%), whereas potentially life-threatening (LT) secondary headaches are less frequent (2–15.3%). Worrying conditions include brain tumors, central nervous system infections, dysfunction of ventriculo-peritoneal shunts, hydrocephalus, idiopathic intracranial hypertension, and intracranial hemorrhage. In the emergency setting, the main goal is to intercept potentially LT conditions that require immediate medical attention. The initial assessment begins with an in-depth, appropriate history followed by a complete, oriented physical and neurological examination. The literature describes the following red flags requiring further investigation (for example neuroimaging) for recognition of LT conditions: abnormal neurological examination; atypical presentation of headaches: subjective vertigo, intractable vomiting or headaches that wake the child from sleep; recent and progressive severe headache (<6 months); age of the child <6 years; no family history for migraine or primary headache; occipital headache; change of headache; new headache in an immunocompromised child; first or worst headache; symptoms and signs of systemic disease; headaches associated with changes in mental status or focal neurological disorders. In evaluating a child or adolescent who is being treated for headache, physicians should consider using appropriate diagnostic tests. Diagnostic tests are varied, and include routine laboratory analysis, cerebral spinal fluid examination, electroencephalography, and computerized tomography or magnetic resonance neuroimaging. The management of headache in the ED depends on the patient's general conditions and the presumable cause of the headache. There are few randomized, controlled trials on pharmacological treatment of headache in the pediatric population. Only ibuprofen and sumatriptan are significantly more effective than placebo in determining headache relief.

Pediatric and Adolescent Headache

PURPOSE OF REVIEW

This article provides the practicing neurologist with a comprehensive, evidence-based approach to the diagnosis and management of headache in children and adolescents, with a focus on migraine.

RECENT FINDINGS

Four triptans are now labeled by the US Food and Drug Administration (FDA) for acute migraine treatment in adolescents, and rizatriptan is labeled for use in children age 6 and older. For preventive migraine treatment, the Childhood and Adolescent Migraine Prevention trial demonstrated that approximately 60% of children and adolescents with migraine will improve with a three-pronged treatment approach that includes: (1) lifestyle management counseling (on sleep, exercise, hydration, caffeine, and avoidance of meal skipping); (2) optimally dosed acute therapy, specifically nonsteroidal anti-inflammatory drugs and triptans; and (3) a preventive treatment that has some evidence for efficacy. For the remaining 40% of children and adolescents, and for those who would not have qualified for the Childhood and Adolescent Migraine Prevention trial because of having continuous headache or medication-overuse headache, the clinician's judgment remains the best guide to preventive therapy selection.

SUMMARY

Randomized placebo-controlled trials have been conducted to guide first-line acute and preventive migraine treatments in children and adolescents. Future research is needed to guide treatment for those with more refractory migraine, as well as for children and adolescents who have other primary headache disorders.

Red flag findings in children with headaches: Prevalence and association with emergency department neuroimaging

BACKGROUND

Clinicians appear to obtain emergent neuroimaging for children with headaches based on the presence of red flag findings. However, little data exists regarding the prevalence of these findings in emergency department populations, and whether the identification of red flag findings is associated with potentially unnecessary emergency department neuroimaging.

OBJECTIVES

We aimed to determine the prevalence of red flag findings and their association with neuroimaging in otherwise healthy children presenting with headaches to the emergency department. Our secondary aim was to determine the prevalence of emergent intracranial abnormalities in this population.

METHODS

A prospective cohort study of otherwise healthy children 2-17 years of age presenting to an urban pediatric emergency department with non-traumatic headaches was undertaken. Emergency department physicians completed a standardized form to document headache descriptors and characteristics, associated symptoms, and physical and neurological exam findings. Children who did not receive emergency department neuroimaging received 4-month telephone follow-up. Outcomes included emergency department neuroimaging and the presence of emergent intracranial abnormalities.

RESULTS

We enrolled 224 patients; 197 (87.9%) had at least one red flag finding on history. Several red flag findings were reported by more than a third of children, including: Headache waking from sleep (34.8%); headache present with or soon after waking (39.7%); or headaches increasing in frequency, duration and severity (40%, 33.1%, and 46.3%). Thirty-three percent of children received emergency department neuroimaging. The prevalence of emergent intracranial abnormalities was 1% (95% CI 0.1, 3.6). Abnormal neurological exam, extreme pain intensity of presenting headache, vomiting, and positional symptoms were independently associated with emergency department neuroimaging.

CONCLUSIONS

Red flag findings are common in children presenting with headaches to the emergency department. The presence of red flag findings is associated with emergency department neuroimaging, although the risk of emergent intracranial abnormalities is low. Many children with headaches may be receiving unnecessary neuroimaging due to the high prevalence of non-specific red flag findings.

Oral dexamethasone for the prevention of acute migraine recurrence in pediatric patients presenting to the emergency department with migraine

Objective:

To assess the feasibility of a randomized controlled trial protocol that aims to determine the efficacy and safety of oral dexamethasone compared to placebo for the prevention of migraine recurrence in children and adolescents visiting the pediatric emergency department (ED) with migraine.

Methods:

This study was a two-arm, parallel-group, randomized, placebo-controlled, double-blind pilot trial of patients presenting to the pediatric ED with migraine. Eligible participants were randomized at 1:1 ratio to receive either oral dexamethasone 0.6 mg/kg (maximum 15 mg) or matched placebo as a single dose. Efficacy and safety outcomes were assessed at discharge, 48 h and 7 days after discharge. The primary outcome of the trial was feasibility and was assessed through participant recruitment rate, follow-up completion rates, participant satisfaction ratings and comparison of enrolled versus non-enrolled participants. Efficacy and safety outcomes were not analyzed given that this was a pilot study.

Results:

Twelve participants were enrolled over the 6-month recruitment period. This represents 60% of the planned sample size and a 10.5% recruitment rate. No other feasibility issues were identified and patients expressed high satisfaction rates with their treatment: 90.9% were satisfied with their treatment at discharge and at 48-h follow-up and 81.8% were satisfied with their treatment at 7-day follow-up (81.8%). There were no significant differences observed when comparing enrolled participants to those not enrolled.

Conclusion:

This pilot randomized controlled trial is the first to assess dexamethasone in the pediatric ED for the prevention of migraine recurrence. The protocol is feasible but recruitment in a single center was lower than expected. Future pediatric ED migraine studies may use innovative or pragmatic trial designs to maximize feasibility from a recruitment standpoint.

Emergency Department Use of Neuroimaging in Children and Adolescents Presenting with Headache

OBJECTIVES

To evaluate emergency department use and outcomes of neuroimaging for headache in a free-standing children's hospital system.

STUDY DESIGN

We prospectively enrolled children aged 6-18 years who presented to the emergency department with a chief complaint of headache from September 2015 to September 2016. Standardized data collection was performed in real time, including telephone follow-up as needed, and imaging outcome was determined through a chart review. Using multivariable logistic regression, we estimated the associations between clinically important patient characteristics and neuroimaging.

RESULTS

Of 294 enrolled patients, 53 (18%) underwent neuroimaging (computed tomography or magnetic resonance imaging) and 2 (0.7%) had clinically important intracranial findings. Presenting with abnormal neurologic examination findings (OR, 11.55; 95% CI, 3.24-41.22), no history of similar headaches (OR, 2.13; 95% CI, 1.08-4.18), and white race (OR, 3.04; 95% CI, 1.51-6.12) were significantly associated with an increased odds of undergoing imaging in multivariable regression models.

CONCLUSIONS

Our observed emergency department imaging rate was 26.5 times higher than our positive result rate, suggesting there is room to decrease unnecessary neuroimaging. Associations for abnormal examination and new headache type are consistent with the American Academy of Neurology clinical imaging recommendations. The increased odds of imaging white patients suggests bias that should be addressed. The low rate of positive findings supports the need for an evidence-based clinical decision tool for neuroimaging in the acute care setting.

PPIENSENLo: A Novel Mnemonics in Spanish for Alarm Criteria in Secondary Headaches in Children

We present the first mnemonic in Spanish, "PPIENSENLo," for alarm criteria in secondary headaches in children in order to facilitate their identification, diagnosis, and treatment. A search was performed across different electronic databases for a mnemonics that applied to clinical alarm criteria in secondary headaches in children. None were found in English or Spanish. This tool is perhaps useful both for clinical and teaching purposes.

Secondary Headaches in Children and Adolescents: What Not to Miss

INTRODUCTION

Headaches are a common occurrence in childhood and adolescence. Most children presenting with a chief complaint of headache have a self-limited infectious disorder or primary headache syndrome that should not require extensive workup.

PURPOSE OF REVIEW

Differentiating these conditions from other more serious causes of headache in children can sometimes be difficult. This article aims to provide information regarding "red flags" that should indicate a need for concern for disorders that require more urgent evaluation.

RECENT FINDINGS

Long-held beliefs about specific "red flags" that have been analyzed in recent years as to their validity and new criteria for the diagnosis of idiopathic intracranial hypertension have been elaborated based on study. These publications are reviewed in this article. Knowledge of past and current literature on secondary headache in children, combined with thorough history taking and examination, should help determine when there is concern for a serious secondary cause for headache in children and adolescents and direct workup.

Occipital Headaches and Neuroimaging in Children

PURPOSE OF REVIEW

The goal of this review is to outline the prevalence and significance of occipital headaches in children and how they relate to neuroimaging findings. We seek to evaluate the concern that occipital headaches in children are indicative of secondary headache pathology by reviewing the yield of neuroimaging in pediatric patients with occipital headache location.

RECENT FINDINGS

Occipital headaches are a common presentation of primary headache disorders in children, seen in 7-16% of children presenting for evaluation of headache and in up to 20% of children diagnosed with migraine in the emergency department. Review of recent literature confirms that in and of itself, occipital location of headache in a child with recurrent headache and a normal physical examination should not be regarded as worrisome. Headaches with associated signs on neurologic examination should be investigated for a secondary cause, regardless of headache location. Occipital headaches that do not meet criteria for a primary headache disorder should be evaluated for site-specific occipital headache conditions. Neuroimaging for recurrent headache in children who have normal neurological examinations has an overall low yield (0-4.1%) for actionable findings in recent studies. Importantly, an abnormal neurologic examination often predicts the presence of neuroimaging abnormalities. In the absence of an atypical history or abnormalities on clinical examination, occipital headaches in children are no more likely to be associated with intracranial pathology than headaches in other locations. If the child's headaches are otherwise consistent with migraine or another primary headache disorder, and the neurologic examination is normal, the yield of neuroimaging is low, and imaging can generally be deferred.

Brain Imaging Findings in Children with Headache

Background:

Headache is a common problem in children, but a small percentage of them have positive findings on CT scan and MRI, and considering that CT scan and MRI is costly and risks of radiation is high for children. Therefore the aim of this study is evaluating CT scans and MRI finding in children with headache.

Materials and Methods:

This cross-sectional study was performed on 353 children with headaches that 217 patients underwent CT and 136 patients underwent MRI. The data collected through the report sheet of CT scan and MRI and analyzed using SPSS software and chi-square test.

Results:

According to the study, 88.9% of MRI and 75.7% of CT scan were normal. Abnormal findings on CT scan was significantly higher in boys (12.2% vs. 9.5%) (P= 0.03) and it was determined that MRI findings was also significantly higher in boys (26.3% vs. 21.5%) (P=0.04). The most common abnormal findings on CT scan was mass (16.6%) and hematoma (16.6%) and the most common abnormal findings on MRI was cysts (26.3%).

Conclusion:

The results of our study showed that the majority of imaging results in patients with headache was normal or benign lesions. Therefore, imaging should be performed only in children with abnormal findings on physical examination.

Experts' opinion about the primary headache diagnostic criteria of the ICHD-3rd edition beta in children and adolescents

BACKGROUND

The 2013 International Classification of Headache Disorders-3 (ICHD-3) was published in a beta version to allow the clinicians to confirm the validity of the criteria or to suggest improvements based on field studies. The aim of this work was to review the Primary Headache Disorders Section of ICHD-3 beta data on children and adolescents (age 0-18 years), and to suggest changes, additions, and amendments.

METHODS

Several experts in childhood headache across the world applied different aspects of ICHD-3 beta in their normal clinical practice. Based on their personal experience and the literature available on pediatric headache, they made observations and proposed suggestions for the primary headache disorders section of ICHD-3 beta data on children and adolescents.

RESULTS

Some headache disorders in children have specific features which are different from those seen in adults and which should be acknowledged and considered. Some features in children were found to be age-dependent: clinical characteristics, risks factors and etiologies have a strong bio psycho-social basis in children and adolescents making primary headache disorders in children distinct from those in adults.

CONCLUSIONS

Several recommendations are presented in order to make ICHD-3 more appropriate for use with children.

Occipital Headaches in Children: Are They a Red Flag?

Occipital headache is considered a risk factor for serious secondary headache pathology. The purpose of our study was to assess the etiology of occipital headaches among children visiting the emergency department. Subjects were children aged 5 to 18 years who were referred to the emergency department due to headaches during the years 2013 to 2014. A total of 314 patients with headaches were seen at our emergency department. Thirty-nine patients had occipital headaches. Viral infections were the most prevalent final diagnosis (97; 31%), followed by migraine (37; 11.8%). None of our patients had a brain tumor. There was no difference in final diagnosis between the occipital and nonoccipital groups. The most common causes of occipital headaches are viral infections and primary headaches. Serious intracranial disorders presenting solely as occipital headaches and not accompanied by other neurologic signs are uncommon. Thus, occipital headaches should be evaluated in the same manner as other headache locations.

Occipital headaches and neuroimaging in children

OBJECTIVE

To investigate the common thinking, as reinforced by the International Classification of Headache Disorders, 3rd edition (beta), that occipital headaches in children are rare and suggestive of serious intracranial pathology.

METHODS

We performed a retrospective chart review cohort study of all patients ≤18 years of age referred to a university child neurology clinic for headache in 2009. Patients were stratified by headache location: solely occipital, occipital plus other area(s) of head pain, or no occipital involvement. Children with abnormal neurologic examinations were excluded. We assessed location as a predictor of whether neuroimaging was ordered and whether intracranial pathology was found. Analyses were performed with cohort study tools in Stata/SE 13.0 (StataCorp, College Station, TX).

RESULTS

A total of 308 patients were included. Median age was 12 years (32 months-18 years), and 57% were female. Headaches were solely occipital in 7% and occipital-plus in 14%. Patients with occipital head pain were more likely to undergo neuroimaging than those without occipital involvement (solely occipital: 95%, relative risk [RR] 10.5, 95% confidence interval [CI] 1.4-77.3; occipital-plus: 88%, RR 3.7, 95% CI 1.5-9.2; no occipital pain: 63%, referent). Occipital pain alone or with other locations was not significantly associated with radiographic evidence of clinically significant intracranial pathology.

CONCLUSIONS

Children with occipital headache are more likely to undergo neuroimaging. In the absence of concerning features on the history and in the setting of a normal neurologic examination, neuroimaging can be deferred in most pediatric patients when occipital pain is present.

Site locked headaches in paediatric patients do not require routine brain imaging and rarely have a serious aetiology

AIM

The main aim of this study was to examine the aetiology and the yield of brain imaging of children with site locked headaches (SLH).

METHODS

This study was carried out at Queen's University Hospital, Essex, UK, from August 2011 to August 2015 and focused on patients who were at least five years of age, had experienced at least five SLH attacks and had a normal neurological examination. Bilateral or alternating unilateral headaches were excluded. Data were collected prospectively, and the headache diagnosis was based on the International Classification of Headache Disorders.

RESULTS

We identified 292 eligible patients (60% female) aged 5.1-17 years: 177 with unilateral SLH, 104 with occipital SLH and 11 with vertex SLH. Anterior headaches were the most frequent (n = 133), and the diagnoses included migraine (n = 192), tension type headaches (n = 30) and medication-overuse headaches (n = 22). The headache was unspecified in 43 cases. Magnetic resonance imaging was normal in 96% of the 283/292 scanned or showed a nonspecific, nonsignificant abnormality in 4%.

CONCLUSION

Site locked headaches were most likely to be caused by primary headaches, particularly migraine. An SLH without abnormal neurological findings is unlikely to have an underlying sinister aetiology, and routine brain imaging is not required in such cases.

The Use of a Pediatric Migraine Practice Guideline in an Emergency Department Setting

OBJECTIVE

The aim of the study was to evaluate the safety and efficacy of a standardized pediatric migraine practice guideline in the emergency department (ED).

METHODS

Migraine Clinical Practice Guideline (MCPG) was created in collaboration with the Division of Pediatric Neurology and Pediatric Emergency Medicine. The MCPG was established on evidence-based data and best practice after a review of the literature. The MCPG was implemented for patients with a known diagnosis of migraine headaches and a verbal numeric pain score (VPS) greater than 6 on a 0 to 10 scale. Patients received intravenous saline, ketorolac, diphenhydramine, and either metoclopramide or prochlorperazine. After 40 minutes, another VPS was obtained, and if no improvement, a repeat dose of metoclopramide or prochlorperazine was administered. If after 40 minutes and minimal pain relief occurred, a consult to neurology was made. A chart review of patients enrolled in the MCPG from April 2004 to April 2013 was conducted. We recorded demographic data, vital signs, ED length of stay, initial VPS, last recorded VPS, adverse events, and admission rate. Nonparametric statistics were performed.

RESULTS

A total of 533 charts were identified with a discharge diagnosis of migraine headache of which 266 were enrolled in the MCPG (179 females and 87 males). Mean (SD) age was 13.9 (3.1). Mean (SD) initial VPS was 7.8 (2.0). Mean (SD) discharge VPS was 2.1 (2.8), representing a 73% reduction of pain. Twenty patients (7.5%) were admitted for status migrainosus; mean (SD) age was 14.0 (3.5) years and mean (SD) VPS was 6.3 (2.8). Mean (SD) length of stay in ED was 283 (107) minutes. No adverse events were identified.

CONCLUSIONS

Our MCPG was clinically safe and effective in treating children with acute migraine headaches. Our data add to the dearth of existing published literature on migraine treatment protocols in the ED setting. We recommend additional prospective and comparative studies to further evaluate the effectiveness of our protocol in this patient population.

Image diagnosis: arachnoid cyst

A 14-year-old boy presented with 3 months of generalized headache that had increased in intensity and frequency with associated light-headedness. Primary arachnoid cysts result from developmental abnormalities; more rare secondary cysts develop as a result of head injury, meningitis, tumors, or as a complication of brain surgery.

New daily persistent headache with isolated sphenoiditis in children

Isolated sphenoid sinusitis is a rare disease in children, and its symptoms are often nonspecific and confusing. Rarely, severe headache can be the first or only symptom of isolated sphenoid sinusitis. New daily persistent headache (NDPH) is a form of chronic daily headache that may have features of both migraines and tension-type headaches. NDPH is difficult to diagnose and requires a multifaceted approach. Here, we report on a 10-year-old boy and an 11-year-old girl who both presented with typical NDPH symptoms. These patients had no nasal symptoms or signs of infection. Neither nonsteroidal anti-inflammatory drugs nor topiramate had any effect on the headaches. Their neurological and ophthalmological examinations were normal. The results of routine blood work, including thyroid function tests, inflammatory markers, complete blood count, tests for viral infection, and a metabolic panel, were normal. A brain magnetic resonance imaging scan showed isolated sphenoid sinusitis. Both patients' symptoms resolved completely after approximately 1 month of oral antibiotics for sinusitis.

Inpatient management of migraine

Migraine is a frequently disabling disorder which may require inpatient treatment. Admission criteria for migraine include intractable migraine, nausea and/or vomiting, severe disability, and dependence on opioids or barbiturates. The inpatient treatment of migraine is based on observational studies and expert opinion rather than placebo-controlled trials. Well-established inpatient treatments for migraine include dihydroergotamine, neuroleptics/antiemetics, lidocaine, intravenous aspirin, and non-pharmacologic treatment such as cognitive-behavioral therapy. Short-acting treatments possibly associated with medication overuse, such as triptans, opioids, or barbiturate-containing compounds, are generally avoided. While the majority of persons with migraine are admitted on an emergency basis for only a few days, outcome studies and infusion protocols during elective admissions at tertiary headache centers suggest a longer length of stay may be needed for persons with intractable migraine.

It IS a tumor -- current review of headache and brain tumor

"Do I have a tumor?" This is a question in every person's mind when first confronted with a new-onset headache, a question that causes considerable anxiety among patients, leading them to seek medical evaluation. This publication reviews the current literature with respect to the epidemiology, pathophysiology presentation, and treatment of headaches in association with intracranial neoplasm.

Association between malocclusion and headache among 12- to 15-year-old adolescents: a population-based study

OBJECTIVES

Headaches are a common problem among adolescents, and malocclusion is a possible risk factor. The purpose of this study was to investigate the association between malocclusion and headache among Japanese adolescents aged 12-15 years using a population-based sample.

METHODS

A total of 938 adolescents (94.7% of the target population in Koshu City) participated. A modified version of the Index of Orthodontic Treatment Need (IOTN) was used by orthodontists to evaluate occlusal characteristics, and the frequency of headaches (none, rarely, sometimes) was assessed via questionnaire (N = 938). Ordered logistic regression analyses were used to analyze the association between malocclusion and headache.

RESULTS

The prevalence of malocclusion diagnosed using the modified version of the IOTN was 44.9%. Multiple ordered logistic regression analyses showed that the odds ratio (OR) of having malocclusion for headache was 1.38 (95% confidence interval [CI]: 1.06-1.80), after adjustment for demographics, lifestyle, and dental status including orthodontic treatment history and tooth size. Moreover, among occlusal traits, lower crowding was independently associated with headache (OR: 1.64, 95% CI: 1.07-2.51).

CONCLUSIONS

We found that malocclusion, especially lower crowding, was associated with headache in a population-based sample of adolescents aged 12-15 years in Japan. Further study is needed to elucidate the mechanisms by which malocclusion affects headache.

Headache in the pediatric emergency service: a medical center experience

BACKGROUND

Headache is a common complaint in children and is one of the most common reasons for presentation at a pediatric emergency department (PED). This study described the etiologies of patients with headache seen in the PED and determined predictors of intracranial pathology (ICP) requiring urgent intervention. A secondary objective was to develop rapid, practical tools for screening headache in the PED.

METHODS

We conducted a retrospective chart review of children who presented with a chief complaint of headache at the PED during 2008. First, we identified possible red flags in the patients' history or physical examination and neurological examination findings. Then, we recorded the brain computed tomography results.

RESULTS

During the study period, 43,913 visits were made to the PED; in 409 (0.9%) patients, the chief complaint was headache. Acute viral, respiratory, and febrile illnesses comprised the most frequent cause of headache (59.9%). Six children (1.5%) had life-threatening ICP findings. In comparison with the group without ICP, the group with ICP had a significantly higher percentage of blurred vision (p = 0.008) and ataxia (p = 0.002).

CONCLUSION

Blurred vision and ataxia are the best clinical parameters to predict ICP findings.

Pediatric headache: where have we been and where do we need to be

In this article, we hope to summarize current understanding of pediatric headache. We discuss epidemiology, genetics, classification, diagnosis, outpatient, emergency and inpatient treatment options, prevention strategies, and behavioral approaches. For each section, we end with a series of questions for future research and consideration.

Yield and clinical efficacy of funduscopic examinations performed in the pediatric emergency room

Consultations by ophthalmologists to rule out papilledema are frequently requested by emergency room (ER) physicians. The clinical setting and optimal timing for examination are not well established, and the impact on patient management is unclear. We evaluated the yield of emergency funduscopic examinations, aiming at establishing the optimal timing and efficacy of the consultation. The medical records of all children aged 0-18 years referred for funduscopic examinations from the ER between June 2010 and May 2011 were reviewed. Of 19,772 ER visits, 1,920 (9.7 %) were seen by an ophthalmologist and 479 (2.4 %) to rule out papilledema. Headache (44.5 %) and head trauma (18.4 %) were the most common indications. Sixty percent of the 479 patients had been symptomatic for <24 h, all having normal eye exams. Only 6/479, with diverse etiologies, depicted papilledema. Among these six children, visual complaints associating with headache were statistically significant to suggest the presence of papilledema (p = 0.014). Seventy-one of the 479 children underwent neuroimaging studies despite normal funduscopic examinations. A single tumor case (medulloblastoma), symptomatic for weeks, had normal funduscopy.

CONCLUSION

The vast majority of ER consultations to rule out papilledema show normal findings, particularly among children with signs and symptoms lasting for <24 h. The yield of funduscopy may be higher if visual disturbances are reported. If neuroimaging studies are considered, emergency room ophthalmological consultation is probably not warranted, except for young infants with neurological signs and symptoms in whom retinal hemorrhages suggestive of physical abuse must be ruled out.

Childhood headaches and brain magnetic resonance imaging findings

BACKGROUND

Headaches are common in children and brain magnetic resonance imaging (MRI) studies are widely used in everyday clinical practice because of increasing demands by parents.

AIM

To determine headache types and to evaluate the frequency and clinical significance of brain MRI abnormalities in children with headache.

METHODS

A total of 449 children (261 male and 188 female with a mean age of 11.16 ± 3.22 years) with headache were included into the study. The criteria defined by International Headache Society were used to classify the headache types.

RESULTS

The causes of headache were migraine in 247 (55.0%), tension-type in 133 (29.6%), secondary in 48 (10.7%), and unspecified headaches in 21 (4.7%) patients. Overall, 324 (72.2%) patients underwent cerebral MRI, which revealed abnormalities in 68 (21.0%) patients. Two (0.6%) patients had cerebral MRI abnormalities relevant to headache, including tumor and hydrocephalus each 1 (0.3%). Twenty-nine (8.9%) patients had incidental cerebral MRI abnormalities including 14 (4.3%) white-matter hyperintensities, 4 (1.2%) old infarcts, 3 (0.9%) Chiari malformations, arachnoid cysts and demyelinating lesions each 2 (0.6%), and subdural hygroma, fibrous dysplasia, pineal cyst and perivascular widening, each 1 (0.3%). Remaining 36 (11.1%) patients had extra-cerebral MRI abnormalities including 34 (10.5%) sinus disease, and 2 (0.6%) adenoid vegetation. Indications for brain MRI were atypical headache pattern or presence of neurologic abnormalities in 59 (18.2%) patients and parents' concerns in 265 (81.8%) patients. The rates of abnormal MRI findings were similar between these 2 groups.

CONCLUSIONS

The most frequent cause of headache in children is migraine. Despite the high rate of imaging abnormalities, the yield of brain MRI is not contributory to the diagnostic and therapeutic approach.

Management of pediatric migraine in a tertiary care versus community based emergency department: an observational pilot study

BACKGROUND

Because of a lack of guidelines for the management of pediatric migraine in the emergency department setting, marked variations in treatment protocols exist between institutions. We aimed to characterize differences in management strategies for pediatric migraine treatment between a community-based and a tertiary care emergency department.

METHODS

A retrospective cohort study was performed to include pediatric patients presenting with headache fulfilling the International Classification of Headache Disorders-2 migraine criteria in a tertiary care (site 1) and a community based (site 2) emergency department. The two sites were compared with respect to patient demographics and approach to treatment.

RESULTS

A total of 158 patients at site 1 (mean age 13.6 years, 70% female, 68% African-American) and 63 patients at site 2 (mean age 16.7 years, 71% female, 100% Caucasian) were analyzed. Opiate use (7.6% vs. 33%), imaging (6.3% vs. 20.6%), use of nonsteroidal anti-inflammatory drugs/serotonin agonists at discharge (72.7% vs. 22.2%), and admission rates to hospital (22% vs. 0%) were significantly different. Logistic regression analysis indicated that the main predictors of hospital admission were use of opiates and intravenous combination abortive therapy.

CONCLUSION

Low rates of intravenous combination therapy, antidopaminergic agent, and serotonin agonist use were noted across both hospital settings. Community-based physicians used opiates and obtained neuro-imaging more than those in the academic setting. Standardization of care in the emergency setting coupled with reliable acute care plans that are based on evidenced-based guidelines can allow for better control of episodic migraine and reduce emergency department visits.

Diagnostic testing and treatment of pediatric headache in the emergency department

OBJECTIVE

To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample.

STUDY DESIGN

This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine.

RESULTS

Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning.

CONCLUSIONS

There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.

Preseason reports of neck pain, dizziness, and headache as risk factors for concussion in male youth ice hockey players

OBJECTIVE

The objective of this study was to determine the risk of concussion in youth male hockey players with preseason reports of neck pain, headaches, and/or dizziness.

DESIGN

Secondary data analysis of pooled data from 2 prospective cohort studies.

SETTING

Ice hockey rinks in Alberta and Quebec, Canada.

PARTICIPANTS

A total of 3832 male ice hockey players aged 11 to 14 years (280 teams) participated.

ASSESSMENT OF RISK FACTORS

Participants recorded baseline preseason symptoms of dizziness, neck pain, and headaches on the Sport Concussion Assessment Tool. Incidence rate ratios (IRR) were estimated using Poisson regression, adjusted for cluster by team, hours of exposure, and other covariates.

MAIN OUTCOME MEASURES

Concussions that occurred during the season were recorded using a validated prospective injury surveillance system.

RESULTS

Preseason reports of neck pain and headache were risk factors for concussion (IRR = 1.67; 95% confidence interval [CI], 1.15-2.41 and IRR = 1.47; 95% CI, 1.01-2.13). Dizziness was a risk factor for concussion in the Pee Wee nonbody checking cohort (IRR = 3.11; 95% CI, 1.33-7.26). A combination of any 2 symptoms was a risk factor in the Pee Wee nonbody checking cohort (IRR = 3.65; 95% CI, 1.20-11.05) and the Bantam cohort (IRR = 2.40; 95% CI, 1.15-4.97).

CONCLUSIONS

Male youth athletes reporting headache and neck pain at baseline were at an increased risk of concussion during the season. The risk associated with dizziness and any 2 of dizziness, neck pain, or headaches depended on age group and body checking.

CLINICAL RELEVANCE

Baseline testing may be of benefit to identify individuals with symptoms of dizziness, neck pain, and headaches who may be at a higher risk of concussion during the season.