What diagnostic tests should be run for a 10-year-old with daily headaches?

Diagnostic Testing for Daily Headaches in a 10-Year-Old Child

For a 10-year-old with daily headaches, a thorough history and physical examination with particular attention to neurological findings and red flags should be performed first, with neuroimaging reserved only for specific concerning features. 1

Initial Assessment

Key History Elements to Obtain:

• Headache characteristics:
  • Age at onset
  • Duration of episodes
  • Frequency pattern
  • Pain location, quality, and severity
  • Aggravating and relieving factors
  • Associated symptoms (photophobia, phonophobia, nausea, vomiting)
  • Presence of aura symptoms

Critical Physical Examination Components:

• Vital signs including blood pressure
• Complete neurological examination
• Optic disc examination (crucial to identify papilledema)
• Head circumference measurement
• Skin examination for neurocutaneous markers

Red Flags Requiring Neuroimaging

Neuroimaging (preferably MRI) is indicated if any of these red flags are present 2, 1:

• Abnormal neurological examination findings
• Papilledema or optic disc changes
• Worsening pattern of headache frequency or severity
• Headaches that wake the child from sleep
• Early morning headaches with vomiting
• Positional headaches
• Headaches unresponsive to standard treatments
• Persistent vomiting
• Visual changes or balance problems
• Personality changes or school performance decline
• Seizures

Diagnostic Testing Algorithm

1. If no red flags present:

   • No neuroimaging is indicated
   • Consider headache diary to track patterns
   • Consider using validated tools like the three-item ID-Migraine questionnaire 2

2. If red flags present:

   • MRI of the brain (with and without contrast) is the preferred imaging modality 2, 1
   • CT may be used in emergency settings when MRI is unavailable or for suspected acute hemorrhage 2

3. Additional testing based on specific concerns:

   • If signs of infection: Complete blood count, inflammatory markers
   • If suspected idiopathic intracranial hypertension: Lumbar puncture (after neuroimaging)
   • If suspected sinusitis: Consider MRI to include paranasal sinuses 2, 3

Important Considerations

• The diagnostic yield of neuroimaging in children with headaches is generally low, with only about 1% having relevant findings that explain their headaches 2
• Cranial autonomic symptoms (like nasal congestion or rhinorrhea) may be mistaken for sinus issues but can occur in primary headaches like migraine 2
• Isolated sphenoid sinusitis can present with severe headache as the only symptom without nasal symptoms 3
• Chronic daily headache is defined as more than 15 headache days per month 4

Common Pitfalls to Avoid

• Ordering neuroimaging for all children with headaches (unnecessary radiation exposure with CT and potential need for sedation with MRI in young children)
• Missing secondary causes by not performing a thorough neurological examination
• Overlooking medication overuse headache in children using frequent analgesics
• Assuming all headaches with nasal symptoms are due to sinusitis

Remember that the majority of children with headaches have primary headache disorders, but a systematic approach to identify those requiring further investigation is essential for proper management and to avoid missing serious secondary causes.