What is the appropriate workup for a 5-year-old presenting with headaches?

Workup for a 5-Year-Old with Headache

The appropriate workup for a 5-year-old with headache should focus on clinical evaluation with neuroimaging reserved only for cases with specific red flags, as neuroimaging is rarely necessary in children with primary headache and normal neurological examination.

Initial Clinical Assessment

History

• Headache characteristics:
  • Temporal pattern (acute, acute-recurrent, chronic progressive, chronic non-progressive)
  • Location (occipital location is concerning 1)
  • Severity and quality (inability to describe quality is concerning 1)
  • Aggravating/alleviating factors
  • Associated symptoms

Red Flags Requiring Immediate Attention

• Neurological abnormalities:

  • Abnormal neurological examination
  • Cranial nerve palsies or strabismus 2
  • Papilledema (present in 60% of children with brain tumors 3)
  • Gait disturbance, abnormal reflexes 3
  • Drowsiness or altered mental status 2

• Concerning headache patterns:

  • Sudden severe ("thunderclap") headache
  • Occipital location (statistically associated with serious disease 1)
  • Progressive worsening headache
  • Headache awakening child from sleep
  • Headache worse with Valsalva maneuver (concerning for Chiari malformation 3)

• Other concerning features:

  • Signs of increased intracranial pressure
  • Recent head trauma
  • Fever with neck stiffness (meningitis)
  • First-degree relatives with aneurysms or vascular abnormalities 3

Diagnostic Testing

When to Order Neuroimaging

According to the ACR Appropriateness Criteria 3 and AAN guidelines 4:

1. No imaging needed if:

   • Normal neurological examination
   • No red flags
   • Features consistent with primary headache

2. MRI indicated if:

   • Signs of increased intracranial pressure
   • Concern for possible tumor
   • Abnormal neurological findings
   • Papilledema
   • Persistent headache with concerning features

3. CT indicated in emergency settings if:

   • Sudden severe headache (to rule out subarachnoid hemorrhage)
   • Signs of acute intracranial pathology requiring immediate intervention
   • When MRI is not available or feasible

Laboratory Studies

• Not routinely recommended without specific indications 4
• Consider if suspecting:
  • Infection (CBC, CRP)
  • Meningitis (lumbar puncture if indicated)

Management Based on Etiology

Primary Headaches

• Most pediatric headaches are primary (migraine or tension-type) 4
• Treatment:
  • Non-opioid analgesics (ibuprofen, acetaminophen) are effective 3
  • Avoid opioids for headache management 3
  • Address sleep hygiene issues 3

Secondary Headaches

• Common causes include:
  • Upper respiratory infections (most common - 57% of acute headaches 1)
  • Sinusitis
  • Viral meningitis
  • Rarely: brain tumors, intracranial hemorrhage, shunt malfunction 1

Important Clinical Considerations

1. Brain tumors in children:

   • 94% have abnormal neurological findings at diagnosis 3
   • 60% have papilledema 3
   • Almost all have other symptoms or neurological signs accompanying headache 3

2. Yield of neuroimaging:

   • Low yield in children with normal neurological examination 3
   • <1% of imaged children have relevant findings explaining headache 3

3. Follow-up considerations:

   • Referral to a headache specialist may reduce emergency department visits 2
   • Consider referral if headaches persist despite appropriate management

Special Situations

• Thunderclap headache: Requires immediate evaluation with non-contrast CT (sensitivity 98% for acute subarachnoid hemorrhage) 3

• Suspected pseudotumor cerebri: Consider MRI with MR venography 3

• Suspected Chiari I malformation: MRI with sagittal T2-weighted sequence of the craniocervical junction 3

Remember that serious underlying causes of headache in children are rare, and when present, they typically present with multiple neurological signs 1.