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Study Calls for Rethinking CT Scans in the ED to Diagnose Children with Headache

For release: Thursday, October 29, 2009

Child with headache holding his head in his hands.

When a child is rushed to the emergency room with an acute headache, the goal for both parents and doctors is to determine if a serious neurological condition might be causing the pain. One option is to perform a computed tomography (CT) scan to aid diagnosis. But CT scans expose children to worrisome levels of radiation, plus they are expensive, raising the question: do the benefits outweigh the risks?

A new analysis of medical records suggests the answer is usually no. The study, published in the July 1, 2009, issue of Pediatrics,* offers evidence that CT scans are of little benefit for diagnosing headache in young children who have normal neurological exams and no history of serious problems.  “CT is usually not useful in this situation, and a careful history and exam are safer and more cost-effective,” said the study’s senior author, Karin Nelson, M.D., scientist emeritus at the National Institute of Neurological Disorders and Stroke and a neurologist at Children’s Hospital National Medical Center in Washington, D.C.

The study authors reviewed the records at a busy, urban pediatric emergency department (ED) over a three-year period, and examined the cases of 364 children from 2 to 5 years old who were seen for headache.  This represented the largest study of its kind and the only one to focus exclusively on preschool-aged children.

The review found that on the basis of initial history and physical examresults, 306 children were diagnosed with secondary headaches (the term used to describe headaches caused by some other underlying disease or medical condition). Most of these headaches were attributed to fever or viral respiratory illnesses.

Of the remaining 58 children who did not have a clearly identifiable cause for the headache, more than a quarter (28%) underwent CT scanning. Nearly all these cases were eventually diagnosed as primary headaches, a category that includes migraine and tension headache. In only one case did the scan reveal a brain stem tumor in a child. He would have required neuroimaging even if he had not complained of a headache, the study authors noted, because his history indicated a buildup of intracranial pressure and his neurological exam results were abnormal.

The authors concluded:  “CT scanning for young children with headache is expensive, poses risks, and usually is without benefit.”  The authors emphasized the importance of a neurological exam and family history for children with headache.  They say that unless there are red flags in either the neurological exam or the history, CT scanning is likely to be unnecessary and uninformative.

When used appropriately, CT scans are fast and beneficial as a means of diagnosing certain life-threatening conditions, but the procedure can have drawbacks. The risk from exposure to ionizing radiation is much greater for children than adults, because their rapidly dividing and developing young tissue is more sensitive to radiation, and because they  have a longer lifetime ahead of them during which radiation-related cancers can develop.

Cost is another factor for not ordering CT scanning in such cases without clear justification, the authors pointed out. In their clinic, the procedure costs more than $1,300.

In spite of the risks and costs, the authors observed a tendency for physicians to order scans for the youngest children in the study.  In addition, the majority of children in the study did not have a documented family history, perhaps because current guidelines do not require it. Examining young children in pain can be difficult, and working in the presence of anxious parents can add to the pressure on ED physicians.  Sometimes the diagnostic approach may be guided more by a fear of being "less than complete" than by evidence-based medicine, the study noted.

Tarannum M. Lateef, M.D., the paper’s first author and a researcher with the Children’s Hospital National Medical Center and the George Washington University School of Medicine in Washington D.C., is now conducting a larger study to examine the usefulness of CT scans for young children with minor head trauma, new-onset seizures, and other indications, as well as headache. 

-By Gregory Roa

*Lateef TM, Grewal M, McClintock W, Chamberlain J, Kaulas H, Nelson KB. “Headache in young children in the emergency department: use of computed tomography.” Pediatrics, Vol. 124 No. 1 July 2009, pp. e12-e17.

Last Modified November 9, 2009