Head CT is Not Indicated for a Child with Post-Football Head Injury and Delayed Headaches
A head CT scan is not indicated for a child who experienced a head injury 5 days ago during football while wearing a helmet, with no loss of consciousness, vomiting, or mental status changes, but who has developed headaches since the day after the injury. 1, 2
Risk Assessment for Pediatric Head Trauma
Very Low Risk Criteria (CT Not Indicated)
Children ≥2 years with minor head trauma who meet all PECARN (Pediatric Emergency Care Applied Research Network) very low-risk criteria do not require CT imaging 2:
- GCS of 15
- Normal mental status
- No clinical signs of basilar skull fracture
- No loss of consciousness
- No vomiting
- No severe injury mechanism
- No severe headache 1
The risk of clinically important traumatic brain injury in these very low-risk patients is <0.05% 2
Timing Considerations
- The American College of Radiology does not recommend imaging for subacute head trauma (>24 hours) when clinical decision rules indicate very low risk 2
- Headaches developing the day after injury without other concerning symptoms fall into the category of post-traumatic headache, which does not necessarily require imaging 2
Post-Traumatic Headache Management
Clinical Considerations
- Post-traumatic headache is common after pediatric traumatic brain injury, occurring in approximately 33% of cases 3
- Headaches that develop after mild head trauma often phenotype as migraine-like and may persist for days to weeks 4, 5
- The presence of headache alone, without other neurological symptoms, is not an indication for CT imaging in the subacute phase 2
Red Flags That Would Warrant Imaging (Not Present in This Case)
- Worsening headache pattern or increasing severity 1
- Development of new neurological deficits 2
- Mental status changes or altered consciousness 2
- Vomiting (especially >2 episodes) 6
- Visual disturbances or other focal neurological symptoms 1
Appropriate Management Approach
Recommended Approach
- Clinical monitoring of headache symptoms is appropriate rather than CT imaging 2, 1
- If headaches persist beyond 3-4 weeks or worsen in character, consider evaluation by a pediatric neurologist for post-concussive syndrome management 4, 5
- MRI may be considered (rather than CT) if headaches persist beyond 3 months or are accompanied by new neurological symptoms 2
Radiation Risk Considerations
- CT scans expose children to ionizing radiation with potential long-term risks 2
- The benefit-risk ratio does not favor CT imaging in very low-risk scenarios like this case 2, 1
Conclusion
Based on multiple clinical guidelines, this child with delayed onset headaches after minor head trauma, without loss of consciousness, vomiting, or mental status changes, does not require a head CT scan 5 days after the injury 2, 1.