Although unnecessary for children with headache and normal history, computed tomography (CT) scans are widely used. This study sought to determine current practice patterns of neuroimaging to diagnose pediatric headache in a variety of treatment settings and to identify factors associated with increased use of neuroimaging.
This retrospective claims analysis included children (aged 3–17 years) with ≥2 medical claims for headache. The primary outcome was CT scan utilization on or after first presentation with headache in a physician’s office or emergency department (ED).
Of 15 836 patients, 26% (4034 patients; mean age: 11.8 years) had ≥1 CT scan, 74% within 1 month of index diagnosis. Patients with ED visits were 4 times more likely to undergo a CT scan versus those without ED visits (P < .001 [95% confidence interval: 3.9–4.8]). However, even outside the ED, use of CT scans remained widespread. Two-thirds of patients with CT scans had no ED use. Among patients with no ED utilization, >20% received a CT scan during the study period. Evaluation by a neurologist was strongly associated with a lower likelihood of CT scan compared with other provider specialties (odds ratio: 0.37; P < .01 [95% confidence interval: 0.30–0.46]).
Use of CT scans to diagnose pediatric headache remains high despite existing guidelines, low diagnostic yield, and high potential risk. Implementing quality improvement initiatives to ensure that CT scans in children are performed only when truly indicated will reduce unnecessary exposure to ionizing radiation and associated cancer risks.
To the Editor
We largely agree with the conclusions by DeVries et al. [1], however we would like to discuss some issues. We strongly support the suggestion not to perform neuroimaging study in absence of significant indicators of severity, such as age under 3 years, awakening because of pain, worsening of the pattern of headache, repetitive vomiting or abnormal neurological signs. Diagnostic studies in general are rarely needed in children without clinical evidence of underlying structural intracranial lesions. Though less than 1% of brain abnormalities in children present with headache as the only symptom, brain tumors still represent the main fear of families. In our experience, both parents and even children ask more and more frequently for neuroimaging study as they suppose that negative results could relief them from anxiety and fears. In this case, the physician should suggest whether to undergo such investigation and which is the most proper technique for the patient. Interestingly, the children visited by a neurologist were less likely to receive CT scan, maybe because of the higher experience of the specialist to individuate risk factors and his capability to reassure families. We are convinced that the ED pediatrician should play the same role and should be properly trained to do it. Children with severity symptoms, but without symptoms of emergency (in particular younger children, who have higher cancer risk associated to ionizing radiation) should undergo MRI rather than CT scan. This is particularly true for those children receiving care from family physicians: they can follow the patients and know their families and anxiety, while the ED physician (visiting them for the first time) could overestimate the clinical picture. On the other hand, also the ED pediatrician should avoid CT scan, if not strictly indicated, and suggest MRI study possibly after short time. Patients with headache who visited the ED were 4 times more likely to undergo a CT scan [1]. In a previous study from our group, 8% of children with headache in our ED underwent neuroimaging, compared to 7.3-41% in other studies [2]. Though MRI is much more informative than CT scan, we feel that the latter is commonly preferred because it is more easily accessed in the ED setting and because it answers more rapidly to the need of anxiety relief of children and their families. The higher anxiety rate reported among patients who didn't undergo CT scan supports our perception, but we should always keep in mind the lifelong cumulative cancer risk due to radiation before asking for a head CT in children. As children with recurrent headache are referred to family physicians or ED many times and the majority of scans are made within 1 month of index diagnosis [1], a possible solution could be referring selected patients to a center for pediatric headache within few weeks since the first visit. We believe this is very important to contain "revolving doors" and to avoid improper, unnecessary and possibly harmful investigations.
REFERENCES
1. DeVries A, Young PC, Wall E, Getchius T, Li C, Whitney J et al. CT scan utilization patterns in pediatric patients with recurrent headache. Pediatrics 2013;132:e1-e8.
2. Scagni P, Pagliero R. Headache in an Italian pediatric emergency department. J Headache Pain 2008;9:83-87.
Conflict of Interest:
None declared