• 
• 

Three Part Question

In [children who present to the emergency department] with [recurrent headaches, neurological abnormalities and recurrent vomiting] should an [MRI scan be done].

Clinical Scenario

A 9 year old child comes to the emergency department accompanied by his mother. The child complains of recurrent headaches which started a month ago. The headaches awakens him from sleep and are worse in the morning. He has also had recurrent vomiting associated with his headaches. On questioning, the childs mother reports that her son tends to be confused during the headache episodes, and that there has been a recent change in her sons personality. You are worried that this child could have a brain tumor. You wonder whether you should refer the child to radiologists for MRI scan of the head.

Search Strategy

Medline 1950-June 2007 using Ovid Interface
Embase 1980 to 2007 Week 22 using Ovid Interface
[(exp headache OR exp brain tumor OR exp brain cancer) AND (exp.emergency department OR accident and emergency.mp) AND (exp neurological abnormalities.mp. OR neurological symptoms.mp. OR exp.hemiplegia OR exp diplopia ) AND (exp vomiting OR emesis.mp. OR vomit.mp.) AND (exp MRI scan OR exp imaging OR exp diagnostic imaging) AND (LIMIT to children AND english)].

Search Outcome

4 papers were identified on Medline of which 1 was relevant and 10 papers were identified on Embase of which 1 was relevant.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Joseph Maytal et al, 1995	133 children, mean age 11.3 years. 78 children with recurrent headaches were scanned. Mean age 11.3 years with recurrent headache were given imaging.	Follow up	Indications for brain imaging and number of children who fulfilled each criteria.	Headache onset at young age <5 years (4). Atypical headache pattern (12). Increasing severity or frequency of headaches (5). Abnormalities on ocular or neurologic examination (6). Headache provoked by change of position of the head (2). Focal symptoms or signs during headaches (7). Systemic symptoms i.e fatigue, weight loss (11). Parental concern about cerebral mass (12). Physician concern about cerebral mass (11). Not specified (17).	The reasons for choosing one imaging method over another method was not specified. 6 children had both CT and MRI scans done and the reasons for this were not indicated.Reasons for giving imaging in 17 of the patients was not specified.
Abu-arafeh, S Macleod, 2005 Scotland	815 children mean age 10.8 years. 142 children scanned.	Follow up study over 7 years.	Indications for neuroimaging in children	Features of cerebellar dysfunction:- ataxia, nystagmus, intention tremor. Features of raised intracranial pressure:- papilloedema, night/early morning vomiting, large head. Focal new neurological deficits:- recent squint, focal seizures. Personality change. Deterioration of school work.	Results were from children who presented to a specialist headache clinic and not from the general population

Comment(s)

Patients were not those who presented to the emergency department.

Clinical Bottom Line

The two studies that were found were follow up studies, so therefore may not necessarily apply to an emergency setting. It seems that children are given imaging based on three criteria; parental anxiety, physician concern, and the presence of neurological abnormalities. The reoccurance of headache attacks does not seem to be a major reason for prompting imaging since only a minority of those individuals with recurrent headaches were given imaging.

References

1. Joseph Maytal, Robert S.Bienkowski, Mahendra Patel, Lydia Eviatar. The value of brain imaging in children with headache. Pediatrics 413-417, 1995 September.
2. Abu-arafeh, S Macleod. Serious neurological disorders in children with chronic headache. Archives of disease in childhood. 937-940, 2005