CT not useful for pediatric headache patients

Jul 5, 2009

Ordering CT examinations for children younger than age 6 who are admitted to an emergency department for a headache seldom aids in diagnosis, exposes the child to unnecessary radiation, and is a waste of money.

While pediatric neurologists and emergency physicians at the Children's National Medical Center in Washington, DC, weren't quite this blunt, they strongly recommended that the medical indications to justify ordering a CT scan should be rethought for pediatric patients.

Researchers conducted a retrospective study to determine whether CT scans led to better acute care of young children with headaches presenting to emergency physicians. After evaluating 36 months of patient records, they determined that taking thorough clinical histories and performing a thorough physical examination would enable the physicians to make an accurate diagnosis for nearly all patients without the need for CT. The study was published in the July issue of Pediatrics (Vol. 124:1, pp. e12-e17).

The records of 364 children between the ages of 2 and 5 who were treated for headaches at the emergency department of Children's National Medical Center between July 1, 2003, and June 30, 2006, were evaluated. On the basis of initial history and physical examination results, 306 patients, or 84%, were diagnosed with secondary headaches, the majority of which were believed to be caused by acute febrile illnesses and viral respiratory syndromes.

Fifty-eight children had no recognized neurologic or systemic disease. Emergency physicians ordered head CT scans for 16 children, or 27.5%. Results were normal for 15 children.

The only child with abnormal findings was diagnosed with a brainstem glioma. He had been complaining of worsening headaches for the five days prior to visiting the emergency department, and experienced significant pain upon awakening. A neurosurgeon who examined the child in the emergency department identified vertical nystagmus, rapid involuntary eye movement.

Follow-up information was available for 43 of the 57 patients ultimately diagnosed with primary headaches. Only five patients were subsequently seen in the neurology clinic over the ensuing 59 months.

None of the follow-up records of these 57 patients ever documented the occurrence of a previously undetected neurologic cause for headaches, according to lead author Dr. Tarannum Lateef of the departments of neurology and emergency medicine.

In addition to concern about exposing a very young child unnecessarily to a high radiation dose, at a cost of $1,361 for the procedure, the researchers stated that not only are CT scans unhelpful, but that they actually may reassure physicians falsely and delay the ordering of more appropriate MRI examinations.