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Practice Parameter: How Should Recurrent Headaches in a Child Be Evaluated?

These new guidelines should help reassure clinicians that routine testing is unnecessary in evaluating children who present with recurrent headaches.

The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society convened an expert panel to review the available evidence on the evaluation of children with recurrent headaches and to recommend clinical management strategies on the basis of this evidence. The committee concluded, "Recurrent headaches occur commonly in children and are diagnosed on a clinical basis rather than by any testing. The routine use of any diagnostic studies is not indicated when the clinical history has no associated risk factors and the child's examination is normal."

Comment: Neurologists are taught that headaches and vomiting can constitute evidence of increased intracranial pressure (potentially caused by a serious condition such as a tumor). So can headaches that awaken children. Yet, both vomiting and head pain on awakening are relatively common among children who present to neurologists for headache evaluation. On the other hand, the yearly incidence of brain tumors in children is about 3 in 100,000. Thus, the probability of finding a brain tumor in a child who presents with recurrent headaches is very low.

The guidelines are eminently reasonable. For example, lumbar puncture is not recommended as a routine procedure for children with recurrent headaches. On the other hand, lumbar puncture is appropriate if a stiff neck accompanies the headache and the clinician has reason to suspect meningitis or a subarachnoid hemorrhage. Similarly, routine use of imaging studies is not recommended, yet imaging studies are considered appropriate if the optic discs are blurred or if the child's caregiver provides information that suggests intracranial hypertension or an intracranial mass. This report has the potential to set the standard for good medical care of children with recurring headaches, to reduce costs, and to comfort neurologists who are concerned about related medical malpractice litigation.

— Alan Leviton, MD

Dr. Leviton is Professor of Neurology, Harvard Medical School, and Head, Neuroepidemiology Unit, Children's Hospital, Boston.

Published in Journal Watch Neurology October 11, 2002

Citation(s):

Lewis DW et al. Practice parameter: Evaluation of children and adolescents with recurrent headaches: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology 2002 Aug 27; 59:490-8.

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