Pediatric headaches with concurrent symptoms are to be taken seriously, and in some instances, imaging is strongly recommended. When determining whether to refer a patient for diagnostic imaging, consider if the patient has the following:
Abnormal neurological exam
Thunderclap (high intensity with abrupt onset) headache pattern in first or worst headache
Immunocompromised
Absence of family history
Atypical features (age of onset < 6 years, etc.)
Refractory headache
Change in pattern of headaches
Headache waking patient from sleep or early morning headaches
Major exertional headaches or positional changes worsen headaches
Occipital headaches
Confusion, mental changes, seizures
When referring a patient to imaging, there are four common diagnostic options that look for different concerns in the brain.
CT scan: major abnormalities, bleeds
MRI: posterior fossa
MRA: occlusion, vasculitis, RCVS, aneurysms, AVMS, etc.
MRV: sinus venous thrombosis, signs of high intracranial pressure (transverse sinus obliteration, sometimes congenital variants)
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