Practice parameter: Evaluation of children and adolescents with recurrent headaches

Objective: The Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society develop practice parameters as strategies for patient management based on analysis of evidence. For this parameter, the authors reviewed available evidence on the evaluation of the child with recurrent headaches and made recommendations based on this evidence. Methods: Relevant literature was reviewed, abstracted, and classified. Recommendations were based on a four-tiered scheme of evidence classification. Results: Thereed, and classified. Recommendations were based on a four-tiered scheme of evidence classification. Results: There is inadequate documentation in the literature to support any recommendation as to the appropriateness of routine laboratory studies or performance of lumbar puncture. EEG is not recommended in the routine evaluation, as it is unlikely to define or determine an etiology or distinguish migraine from other types of headaches. In those children undergoing evaluation for recurrent headache found to have a paroxysmal EEG, the risk for future seizures is negligible; therefore, further investigation for epilepsy or treatments aimed at preventing future seizures is not indicated. Obtaining a neuroimaging study on a routine basis is not indicated in children with recurrent headaches and a normal neurologic examination. Neuroimaging should be considered in children with an abnormal neurologic examination or other physical findings that suggest CNS disease. Variables that predicted the presence of a space-occupying lesion included 1) headache of less than 1-month duration; 2) absence of family history of migraine; 3) abnormal neurologic findings on examination; 4) gait abnormalities; and 5) occurrence of seizures. Conclusions: 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. NEUROLOGY 2002;59:490–498 Headaches are common in children and become increasingly more frequent during adolescence. In 1962, Bille1 published his landmark epidemiologic survey of headache among 9,000 school children documenting that more than one third of 7-year-old children and half of 15-year-old children reported having had at least one headache. Data from 5 retrospective studies published between 1977 and 1991 of 27,606 children found the prevalence of any type of headache to range from 37 to 51% in 7 year olds, gradually increasing to 57 to 82% by age 15 years.2-6 Prepubertal boys were also found to be more affected with headache than girls, whereas after puberty, headaches were found more commonly in females. QSS Educational Statement: The Quality Standards Subcommittee (QSS) of the American Academy of Neurology seeks to develop scientifically sound, clinically relevant practice parameters for neurologists for diagnostic procedures, treatment modalities, and clinical disorders. Practice parameters are strategies for patient management that might include diagnosis, symptom, treatment or procedure evaluation. They consist of one or more specific recommendations based on analysis of evidence. From the Department of Pediatrics (Drs. Lewis and Dorbad and G. Dahl), Children’s Hospital of the King’s Daughters, Eastern Virginia Medical School, Norfolk, VA; the Department of Pediatrics (Dr. Ashwal), Loma Linda University School of Medicine, CA; NINDS (Dr. Hirtz), Bethesda, MD; Department of Pediatrics (Dr. Prensky), St. Louis Children’s Hospital, St. Louis, MO; and MCP-Hahnemann University School of Medicine (Dr. Jarjour), Allegheny General Hospital, Pittsburgh, PA. Approved by the AAN Standards Subcommittee December 8, 2001. Approved by the AAN Practice Committee April 17, 2002. Approved by the AAN Board of Directors June 8, 2002. Approved by the CNS Practice Committee April 15, 2002. Approved by the CNS Executive Committee April 15, 2002. Address correspondence and reprint requests to American Academy of Neurology, 1080 Montreal Avenue, St. Paul, MN 55116. 490 Copyright © 2002 by AAN Enterprises, Inc. The prevalence of migraine headache in children has also been studied extensively.7-12 Based on data from six retrospective case series between 1962 and 1994 of 13,130 children and adolescents, prevalence data for migraine headache by age groups were: 3 to 7 years old—1.2 to 3.2% (male [M] female [F]); 7 to 11 years old—4 to 11% (M F); and 11 to 15 years old: 8 to 23% (F M).7-12 The evaluation of a child with headache begins with a thorough medical history followed by methodical physical examination with measurement of vital signs, particularly blood pressure, and a complete neurologic examination including examination of the optic fundus. Diagnosis of primary headache disorders of children rests principally on clinical criteria as set forth by the International Headache Society.13 Clues to the presence and identification of secondary causes of headache are uncovered through this systematic process of history and physical examination. The principle indication for performance of ancillary diagnostic testing rests on information or concerns revealed during this fundamental process. There is a lack of consensus concerning the role of diagnostic testing including routine laboratory testing, CSF examination, EEG, and neuroimaging with CT or MRI. This is due in large part to the lack of well-designed prospective studies involving sufficient numbers of patients with specifically defined types of headaches that could address these issues. Such information would be extremely valuable for patients, their families, and their physicians in developing effective evaluation strategies. Before reviewing the evidence and recommendations related to diagnostic testing in children with recurrent headaches, it is important to consider that a child may present acutely with a severe headache that may require the physician to consider urgent or emergent testing to determine whether an underlying systemic disease process is present. For example, if subarachnoid hemorrhage, acute or chronic meningitis, idiopathic intracranial hypertension, or certain other conditions are suspected, lumbar puncture with opening pressure measurement and appropriate ancillary testing are indicated. The presence of headache accompanied by fever or in the immunocompromised patient must raise concerns for infections such as meningitis, either bacterial or viral. If the clinical examination demonstrates nuchal rigidity with or without alteration of consciousness, signs of increased intracranial pressure, mental status changes, or lateralizing features, neuroimaging followed by lumbar puncture may need to be performed.14 This practice parameter reviews available evidence concerning the value of diagnostic testing in children and adolescents who report recurrent headache and provides recommendations based on this evidence. Headache types reviewed in this parameter include migraine, tension-type, and other primary headache disorders, as well as headaches that are secondary to other conditions or syndromes as outlined by the International Headache Society.13 It pertains to children, 3 to 18 years old, who present for the evaluation of recurrent headache unassociated with trauma, fever, or other obvious provocative causes. Methods. Computer-assisted literature searches were conducted with the assistance of the University of Minnesota Biomedical Information Services Research Librarian for relevant articles published from 1980 to 2000. Databases searched included MEDLINE and CURRENT CONTENTS using the following “key words”: headache, migraine, tension-type headache, electroencephalography, computed tomography, magnetic resonance imaging, blood chemical analysis, neurological examination, diagnostic errors. In addition, the database provided by CURRENT CONTENTS was searched for the most recent 6-month period. Five selected articles published before 1980 that were found in bibliographies of recent publications also were included as they contained important epidemiologic data from large case series of children.2,7,10-12 The age qualifier of 3 to 18 years was selected, as this is the age group, based on previous literature, when most children are seen for pediatric or neurologic evaluation. Searches included titles from English and non-English language journals. Only those articles reporting studies with more than 25 patients were included. Articles consisting of single patient case reports or small samples of unusual pathologic findings, which would have biased the analysis, were excluded. Only studies that contained information about the patients’ neurologic examinations were included. A bibliography of the 398 articles identified and reviewed for preparation of this parameter is available at the American Academy of Neurology (AAN) Web site (http://www.aan. com). Relevant position papers from professional organizations also were reviewed. Individual committee members reviewed titles and abstracts for content and relevance. Those articles dealing with investigations of headache with reference to determining a possible etiology were selected for further detailed review. Bibliographies of the articles cited were checked for additional pertinent references. Each of the selected articles was reviewed, abstracted, and classified by at least two committee members. Abstracted data included the number of patients, age, sex, nature of subject selection, case-finding methods (prospective, retrospective, or referral), inclusion and exclusion criteria, headache type and characteristics, neurologic examination, and the results of laboratory, EEG, or neuroimaging tests. A four-tiered classification scheme for diagnostic evidence recently approved by the Quality Standards Subcommittee was used as part of this assessment (table 1). Depending on the strength of this evidence, it was decided whether specific recommendations could be made, and if so, the strength of these recommendations (table 2). Evidence pertinent to each diAugust (2 of 2) 2002 NEUROLOGY 59 491 agnostic test together with the committee’s evidenced-based recommendations is presented. Laboratory studies and lumbar puncture. Should laboratory studies including lumbar puncture be performed in children with recurrent headache? Evidence. A review of the literature disclosed only one class III study of 104 children who were being evaluated by a pediatric neurologist in whom laboratory studies including complete blood count, electrolyte levels, liver function profiles, and urinalysis were performed by the referring pediatrician.15 The laboratory studies were described as “uniformly unrevealing” but the number of patients studied and specific laboratory data were not described. No other reports investigating the role of laboratory studies in the evaluation of recurrent headache in children or adolescents have been published. One class II prospective study of 193 adults with migraine headache who had laboratory testing (complete blood count, sedimentation rate, serology, urinalysis, and chest x-ray) did not find any clinically relevant diagnostic information.16 Literature review disclosed no studies concerning the role of routine lumbar puncture in the evaluation of headache in children and adolescents. The AAN has published a parameter on diagnostic and therapeutic indications for performing lumbar puncture in adults and children, which did not include recurrent headache as an indication.17 Recommendations There is inadequate documentation in the literature to support any recommendation as to the value of routine laboratory studies or performance of routine lumbar puncture in the evaluation of recurrent headache in children (Level U; class IV evidence). EEG. Should an EEG be performed in children with recurrent headaches? The role of EEG and the controversies surrounding its attendant use in the evaluation of recurrent headaches in children has been the subject of several reviews.18-20 In spite of recommendations not to include the EEG as part of the routine evaluation of children with recurrent headache, it is not uncommon in clinical practice for an EEG to be obtained. A previously published practice parameter by the AAN addressed this issue in adults and came to the conclusion that an EEG was not useful in the routine evaluation of a patient with recurrent headaches.21 The parameter did not exclude the use of EEG to evaluate patients with recurrent headache who had associated symptoms suggesting a seizure disorder. Data from published studies on the use of the EEG in the evaluation of recurrent headaches, particularly in children, are difficult to interpret.18 Methodologic problems range from the patient population having mixed types of headaches, ill-defined headache diagnostic criteria, multiple age groups, lack of comparisons of the study population to agematched control subjects, unclear definitions of EEG abnormalities, and the fact that certain EEG abnormalities previously considered abnormal in children are currently not considered pathologic. Table 1 AAN evidence classification scheme for a diagnostic